Narrative/interpretive perspective and Critical Medical (Health) Anthropology perspective of Malaria in Bangladesh. ( 5 pages )

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Title: Introducing medical anthropology : a discipline in action / Merri\ ll Singer, University of Connecticut, Hans A. Baer, University of Melbourne, Debbi Long, RMIT Uni\ versity, Alex Pavlotski, Aukland University.

Description: Third Edition. | Lanham : ROWMAN & LITTLEFIELD, [2019] | “Second edition 2012”—T.p. verso. | Includes bibliographical re\ ferences and index. | Identifiers: LCCN 2018048811 (print) | LCCN 2018051819 (ebook) | I\ SBN 9781538106471 (electronic) | ISBN 9781538106457 (cloth : alk. paper) | ISBN 978153\ 8106464 (paper : alk. paper) Subjects: LCSH: Medical anthropology.

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Printed in the United States of America Preface ix About the Authors xi 1 Introduction to the Anthropology of Health 1 Introduction and Overview 1 Encountering Health Anthropology 1 Three Case Studies in Applied Health Anthropology 2 Coping with Cystic Fibrosis 2 The Bone Crusher 3 Pesticide Poisoning 5 Practical and Theoretical Contributions of Health Anthropology 8 Clarifying the Culture of Health and Illness 8 Health Inequality 9 Defining Health Anthropology 10 Culture and Biology 10 History of Health Anthropology 12 The Straits Expedition 12 W. H. R. Rivers and Beyond 14 Rudolf Virchow 15 Er win Ackerknecht and William Caudill 15 The Postwar Period 15 Health Anthropology and National Development 16 The Discipline Is Born 16 The Relationship of Health Anthropology to Anthropology and to Other Health-Related Disciplines 17 Health Research and the Subfields of Anthropology 17 Health Anthropology and Epidemiology 20 Illness and Help-Seeking Behavior 24 Health Anthropology and Public Health 24 Health Anthropology and Bioethics 31 Health Anthropology Theories 32 Medical Ecology 32 Meaning-Centered Health Anthropology 33 Critical Health Anthropology 34 2 What Health Anthropologists Do 37 Introduction and Overview 37 Contents iii iv Contents Three Settings, Three Case Studies, Three Health Anthropologists 37 Life and Death in Tanala 37 Studying Surgeons 39 Folk Illness in Haiti 41 A Case Study 43 Having Impact 43 What Health Anthropologists Study 44 A Diverse Discipline 44 Studying the Life Course 46 Conducting Research: A Peculiarly Anthropological Approach 49 Holistic, Field-Based Understanding 49 Ethnography 49 Complex Sociocultural Tapestries 52 Research Methods 54 Multimethod Research 54 Examining Lives 55 Focus Group Inter views 56 Considering Consensus 57 Doing Diaries 57 Quantitative Methods 58 Broader Collaboration 59 Health Anthropology in Use 59 Mobilizing Research Findings 59 The Health Anthropology Crystal Ball 61 3 Understanding Health, Illness, and Disease 65 Introduction and Overview 65 Conceptions of Health and Illness 65 Defining Terms 65 Differentiating Disease and Illness 66 Reconceptualizing Disease and Illness 69 Understanding Cure 69 Folk Understandings 70 Understandings of Disease Causation 71 Humanizing Biomedicine 73 Sufferer Experience 73 Experience and Cultural Symbols 73 Cultural Emotions 74 Social Suffering 76 Beyond Social Suffering 77 Disability and Chronic Illness 78 The Patient in the Body 78 The Cultural Construction of Disability 79 Contents v Stigmatization 82 Human Rights and Health 83 Illness Narratives 85 The Social Uses of Narration 86 Analyzing Narrative 86 Embodied Health Experience 88 Why Bodies? 88 Body Theor y 89 Bodies in the Age of Immunology 90 Cyborg Bodies 91 Mindful Bodies 92 Engendered Bodies 95 Understanding Medicalization 95 Healer versus Sufferer Conception of Disease 96 The Two Sides of Compliance 96 Insider and Outsider Assessments of Health Status 98 One Word, Two Meanings 98 Diseased but Not Ill 99 Mismessaging 99 Analyzing Health Discourse 100 4 Health Disparity, Health Inequality 102 Introduction and Overview 102 What Is Health Disparity? 102 Health Disparity in the United States 103 Gasping for Breath 104 Causes of Health Disparity: Lifestyle versus Social Inequality 106 Living Right 106 Structural Explanation 106 Biology of Poverty 108 Insuring Disease 109 Culturally Competent Care 110 Health and Social Disparities Cross-Culturally 113 Child and Maternal Health Disparities 116 Addressing Health Disparities 121 Addressing Health Disparities in the Community 121 Upstream Analyses of Health Disparities 122 Gender and Global Health 124 Focusing on Disparity in Diseases 125 Multidisciplinar y Approaches 126 Studying Local Mediation of Global Health 126 vi Contents Pushing Back on Health Disparities 128 “Race” and Health Disparity 128 Race and Racism 129 5 Health and the Environment: Toward a Healthier World 131 Introduction and Overview 131 Medical Ecology and Critical Health Anthropology on the Environment 132 Health and the Environment in the Past 134 Health and the Environment Today 136 Depletion of Natural Resources and Environmental Degradation 137 Capitalism and Climate Change 139 Infectious Diseases in a Globalizing World 140 The Impact of Climate Change on Health 141 Other Environmental Impacts on Health 145 Water and Globalization 146 The Political Ecology of Cancer 148 Cancer in the Community 149 Cancer and Industr y 150 China’s Cancer Villages 151 Anthropological Examinations of Cancer Treatment 152 Nuclear Reactors and Health 152 Unconventional Natural Gas Extraction and Health 153 The Impact of Private Motor Vehicles on Health 154 The Political Ecology of AIDS: Assessing a Contemporary Syndemic 155 6 Ethnomedicine: The Worlds of Treatment and Healing 159 Introduction and Overview 159 Approaching Ethnomedicine 159 Indigenous and Folk Medicine Systems 162 Ways of Healing 162 Typologies of Healing Systems 163 An Evolutionary Model of Disease Theories and Healing Systems 165 Health, Illness, and Medicine in Family-Level Foraging Societies 166 Health, Illness, and Medicine in Village-Level Societies 169 Health, Illness, and Medicine in Pastoralist Societies 170 Health, Illness, and Medicine in Chiefdom Societies 171 Contents vii Folk Healers in Modern Societies 171 Case Study: Are the Therapeutic Aspects of Religion Something That Partially Address Refugee Health Problems? 173 Biomedicine as the Predominant Ethnomedicine in Modern Societies 175 Hospitals 176 Health Anthropology and the Pharmaceutical Industr y 178 7 Plural Medical Systems: Complexity, Complementarity, and Conflict 182 Introduction and Overview 182 A Case Study of Medical Pluralism in a Rural Area in a Developing Society: The Altiplano of Bolivia 183 Themes 183 Medical Subsystems 184 Status of Health Care in Bolivia in the Pre-Revolutionar y Era 184 Social and Health Conditions in Bolivia after the Election of Indigenous\ President Evo Morales 185 A Case Study of Medical Pluralism in an Urban Setting of a Developing Society: A View from Central Java 188 Medical Subsystems 188 A Case Study of Medical Pluralism in a Developed Society: The Australian Dominative Medical System 190 Medical Subsystems 190 Typologies of Plural Medical Systems 195 Healing and Histor y 196 Patients of CAM 199 CAM and Class 201 New Directions in the Study of Medical Pluralism 207 Medical Syncretism 208 Medical Diversity 209 Medicoscapes 210 The Globalization of Traditional Medicine and CAM 210 8 The Biopolitics of Life: Biotechnology, Biocapital, and Bioethics 212 Introduction and Overview 212 Critical Health Anthropology and Biotechnology 212 Science, Nature, and Culture 213 Biocapital: Bodies of Profit 215 viii Contents Reproductive Technologies 216 Divisible Bodies 220 Bringing the Lab into the Field: Anthropology and the Neurosciences 222 Molecular Biotechnologies: Tiny Pieces, Giant Infrastructures 224 The Story of hGH—Growing up Growth Hormone 227 The Culture of PCR 228 Visualization Technologies 229 When Technologies Combine 230 Ancestry, Families, and Genetics: Biotechnology and Belonging 233 9 Strategies and Visions for a Healthier World 240 Introduction and Overview 240 Global Capitalism 240 Democratic Eco-Socialism as a Pathway for a Healthier World 242 Health Anthropology as an Action-Oriented Endeavor 247 Source Material for Students 251 Glossary 255 References 260 Index 300 Students often do not bother with the prefaces to assigned textbooks, an\ d for understandable reasons. The comments of authors about their book are not\ going to be on any test and it is the contents of the book, its ideas, c\ oncepts, theory, and examples, not the book as a product of author labor or the g\ oals and intentions of authors, that is of most immediate concern to the student \ reader.

We hope, in this instance, that these remarks capture some student attention because they deal with an important conceptual issue and provide a glimp\ se behind the curtain of book publishing. When the first (2007) and sec\ ond (2012) editions of this book were published, the authors recognized that while medical anthropology was not the most fitting name for the field our book wa\ s introduc- ing to students, it was the established and widely accepted term. Indeed\ , medical anthropology was a label that smuggled in a lot of problematic baggage. \ Since the last edition, however, our discomfort grew to the point that in 2016\ , along with our colleagues Debbi Long and Pamela Erickson, we published a paper\ in a leading anthropology journal entitled “Rebranding Our Field: Tow\ ards an Articulation of Health Anthropology.” We feel strongly that the time \ has come to retitle medical anthropology using a more appropriate label that bett\ er reflects conceptual developments in the field. Our subfield, as shown clearly\ in the chap- ters of this book, has a wide range of concerns that includes a keen foc\ us on biomedicine and other ethnomedical and health-care traditions. But the w\ ork of those we have come to call “medical anthropologists” addresses mul\ tiple other issues that are not specific to medicine or healing, including underst\ anding health and illness within society and within the complex social and political-e\ conomic systems created by globalization. Consequently, we proposed the name “\ health anthropology”; this better describes the core issue that unites the s\ ubfield.

We called for dropping the term medical anthropology because, as has lon\ g been recognized by many in the field, it is limiting and misleading, and re\ flects the hegemony of biomedicine at various levels. This renaming does not preclu\ de health anthropologists working on or within biomedical, complementary, and alternative medical or indigenous medical settings, as reflected in th\ e fieldwork of all of the coauthors of this book. It was our intention, however, that i\ n its third edition this book be renamed Introducing Health Anthropology: A Discipline in Action to reflect the true breadth of the field. This is where good intentions ran into marketing realities. Our book, and its title, were known, and Introducing Medical Anthropology was widely used as a textbook, the second-best-selling core text on the market in our topical niche.

In our publisher’s reasonable approach to their business it was not s\ een as a good idea to change the title of an established text. The book was seen \ as having instant name recognition for professors who might assign it in a class. \ Changing the title, the publisher felt, could cause confusion to teachers and to \ bookstores looking to order books for classes. As one reviewer of our proposed name\ change commented, “Why not continue to use it as a marketing tool to appeal to the Preface ix x Preface widest number of folks?” For these reasons, the title has not changed\ in the third edition, but the text has been updated to reflect our concerns on this\ matter.

Throughout this text, if not on the cover, we use the terms “health a\ nthropol- ogy,” “health-oriented anthropology,” and “health anthropolo\ gists.” One thing that has changed is the addition of Debbi Long and Alex Pavlotski as coauthors, which, based on their areas of expertise and fi\ eldwork experience, allow us to further examine the wide range of issues investi\ gated in a health-oriented anthropology. One of the goals of the third edition of this book is to affirm that health-oriented anthropologists are very involved in the process of help\ ing, to varying degrees, to change the world around them through their work in a\ pplied projects, policy initiatives, and advocacy. Not all anthropologists teac\ h in a col- lege or university—many are involved full time in directly applied wo\ rk—and most who do teach medical anthropology courses are involved in applicati\ on.

Moreover, as the landscape of academia endures major transformations, wi\ th underpaid adjunct labor now increasingly replacing stable faculty positi\ ons, anthropologists must find creative ways to bring their skill-sets out \ of the ivory tower and into the world. Our subdiscipline both addresses specific he\ alth issues and analyzes them in their broader context. In other words, we seek to u\ nder- stand health-related issues and to use this knowledge in improving human\ health and social well-being. A second goal of this book is a presentation of the fundamental importan\ ce of culture and social relationships in health and illness. Through a rev\ iew of the key ideas, concepts, methods, and theoretical frameworks that guide rese\ arch and application in health-oriented anthropology, the book makes the case\ that illness and disease involve complex biosocial processes and that resolvi\ ng them requires attention to a range of factors beyond biology, including local\ systems of belief, structures of (often unequal) social relationship, the deve\ lopment and globalization of new technologies, and environmental and climatic condit\ ions. Finally, through an examination of the issue of health inequality, such \ as exposure to pesticides among farmworkers, unequal access to health care,\ the role of poverty in the spread of disease, or environmental degradation a\ nd envi- ronment-related illness, this book underlines the need for an analysis t\ hat moves beyond cultural or even ecological models of health toward a comprehensi\ ve biosocial approach. Such an approach integrates biological, cultural, and social factors in building unified theoretical understandings of the origin o\ f ill health, while contributing to the building of effective and equitable national h\ ealth-care systems. In this manner, health anthropologists have a broad vision of p\ lanetary health and seek to be part of a collective process aimed at creating a healthier world for both humanity and the biosphere. The ultimate goal is prevaili\ ng over the social causes of disease, the structures of social injustice th\ at diminish well-being, and the social forces driving environmental destruction, inc\ luding human-created or anthropogenic climate change. For us, ultimately, bring\ ing these issues into the classroom, especially in a time when health has be\ come a daily issue of deep concern, is of far greater importance than the speci\ fic way the field is labeled. Merrill Singer is professor in the Departments of Anthropology and Com- munity Medicine at the University of Connecticut. Dr. Singer has publish\ ed 290 scholarly articles in peer-reviewed journals and book chapters, and \ has authored, co-authored or edited thirty-three books. His research and writing have addressed syndemics, HIV/AIDS and STDs in highly vulnerable and dis\ ad- vantaged populations, illicit drug use and drinking behavior, infectious disease, community and structural violence, and the political ecology of health, \ including the health consequences of climate change. Dr. Singer has been awarded t\ he Rudolph Virchow Professional Prize, the George Foster Memorial Award for\ Practicing Anthropology, both the AIDS and Anthropology Research Group’\ s Distinguished Service Award and its Clark Taylor Professional Paper Priz\ e, the Prize for Distinguished Achievement in the Critical Study of North Ameri\ ca, and the Solon T. Kimball Award for Public and Applied Anthropology from \ the American Anthropological Association.

Hans A. Baer is Principal Honorary Research Fellow in the School of Social Political Sciences at the University of Melbourne. He has published twen\ ty-one books and some 190 book chapters and articles on a diversity of research\ top- ics, including Mormonism, African American religion, sociopolitical life\ in East Germany, critical health anthropology, medical pluralism in the United S\ tates, United Kingdom, and Australia, the critical anthropology of climate chan\ ge, and Australian climate politics. His most recent books are Democratic Eco-Socialism as a Real Utopia (2018), and Urban Eco-Communities in Australia: Real Utopias or Market Niches? (with Liam Cooper, 2018).

Debbi Long is senior lecturer in global studies at RMIT University (Melbourne, Australia). She is a critical health anthropologist and a pioneer of ho\ spital eth- nography in Australia. She is an experienced health ethnographer, having\ under- taken fieldwork in Turkey, Swaziland (eSwatini), and in a variety of\ contexts in Australian public hospitals, including maternity, spinal, intensive care\ , and dialy- sis units. She has worked as a consultant in clinical organization and m\ anagement on projects including quality improvement, patient safety, behavior change, and in industrial relations contexts. Recent research has included family vi\ olence education and compensation industry analysis. She has taught at undergra\ duate and postgraduate levels in anthropology departments; international development programs; medical, nursing, and allied health programs; and in indigenou\ s foun- dation and support programs.

Alex Pavlotski is teaching fellow at Auckland University, New Zealand, and an honorary research fellow at Latrobe University in Australia. He is an\ anthro- pologist and graphic artist. Alex has conducted fieldwork with comic a\ rtists in About the Authors xi xii About the Authors Japan, and in Australia with an urban LGBTQI+ community; with CEOs and accountants across the country; and with recipients of government disabi\ lity payments. His PhD thesis was on the global movement subculture of parkou\ r, a multisited ethnography undertaken across twenty-four cities in eight n\ ations.

His research interests are psychological and neuroanthropology, visual r\ epresen- tation in ethnography, cross-cultural communication, masculinity in lead\ ership research, organizational ethnography, systems design, mind-body connecti\ vity, and reactionary identities. 1 1 Healing requires a legitimated, credible and culturally appropriate syst\ em. —Mildred Blaxter (2004:43) Introduction and Overview I n this chapter, we begin the process of defining and differentiating hea\ lth an- thropology in light of the range of disciplines concerned with health. W\ e initi- ate this introduction to health anthropology by presenting three case st\ udies. We then address both the practical and theoretical work and contributions o\ f health anthropology, differentiate health and illness as technical terms in the\ discipline, engage the issue of health inequality, review the history of health anthropology, and compare and contrast health anthropology with other health-related fields including discussion of multidisciplinary collaboration. Encountering Health Anthropology People who encounter the term medical anthropology, or, as explained in the preface, “health anthropology,” for the first time often are puz\ zled by what it means. Is it the study of how medicine is practiced, what doctors, nurse\ s, or traditional healers from other health-care systems actually do? Or is it\ the study of what it means and feels like to be sick? Perhaps it is the study of f\ olk illnesses in different societies? Might it be the application of cultural knowledg\ e to the actual treatment of diseases? All these questions, in fact, can be answe\ red in the affirmative. Health anthropology addresses each of these issues—and\ far more.

A starting premise of health anthropology is that health-related issues,\ including disease and treatment, how and why one gets sick, and the nature of reco\ very, are far more than narrow biological phenomena. These processes are all heavi\ ly influ- enced by environmental, political-economic, social-structural, and socio\ cultural factors as well. Consequently, health anthropology has developed a bio-sociocul- tural approach in its effort to address health as an aspect of the human condition. To take one example, health anthropologists ask questions such as the following: Could we really understand the AIDS pandemic and respond to i\ t effectively simply by studying the human immunodeficiency virus, its i\ mpact on cells of the body, and medical interventions designed to stop the vir\ us from destroying the immune system? Would we not also need to know how to reac\ h and effectively engage those who are at greatest risk for infection, to figure out the structural and situational factors that contribute to their involvem\ ent in risky behaviors, to know how much they know and what they feel about AIDS and \ how these factors influence their behaviors, and to determine whether \ the ways Introduction to the Anthropology of Health 1 CHAPTER 1 INTRODUCTION TO THE ANTHROPOLOGY OF HEALTH 2 Chapter 1 we go about interacting with them in the community and in the clinic dra\ w them closer or push them away from our treatment programs? In other words, be\ yond biology clearly there are critically important areas of knowledge in the\ ongoing fight against the now about forty-year-old AIDS epidemic. Now, if we t\ hink about the AIDS epidemic as a global problem, a global pandemic, with dif\ ferent routes of infection, different populations at risk, different beliefs an\ d behaviors associated with HIV/AIDS in diverse settings, and different health-care \ systems in different parts of the world or even different parts of a single coun\ try, we begin to get an initial sense of why a social science like anthropology \ might—as it certainly has—have a significant role to play in addressing the \ AIDS epidemic.

This is of no small importance; we know from available research that HIV\ / AIDS is destined to take a greater toll on our species, proportionately \ and in terms of absolute numbers, than the bubonic plague, smallpox, and tuberc\ ulosis combined. Consider the epidemic in South Africa, the country with the hi\ ghest burden of HIV/AIDS in the world. As Didier Fassin (2007a:261) points out, “In one decade, the rate of HIV infection went from less than 1 perce\ nt to over 25 percent of the adult population and AIDS became the main cause of dea\ th for men and women between 15 and 49 years of age,” with an expected d\ rop in average life expectancy in the country of as much as twenty years. Mo\ reover, the global pandemic has helped to shape the social, cultural, and health\ worlds of people all over the planet, whether or not they are always aware of i\ t. Within the broader story of the devastating impact of HIV/AIDS, however, there \ are many differing local narratives that together comprise the complex mosai\ c of the pandemic. The work of health anthropologists has been part of that s\ tory in many places and the same is true for a vast array of other health issues\ . Moreover, health anthropology, while sometimes contributing to cultural explanatio\ ns of HIV/AIDS risk behavior, has struggled in recent years to counter explana\ tions that fail to address the fact that the global economy or capitalism and \ social inequality are the primary driving forces in the epidemic (Hlabangane 2\ 014).      Three Case Studies in Applied Health Anthropology Coping with Cystic Fibrosis The Reynolds family has two children. Carl is five and Stuart is seven. The younger of the two boys has cystic fibrosis (CF), the most common fatal genetic disease in the United States. Cystic fibrosis causes the body to produce a thick- ened form of mucus that clogs the lungs, leading to repeated bacterial infec - tions and increasing lung damage. While the median age of survival among CF sufferers has been rising, most people with the disease do not live very far i\ nto adulthood before they succumb. Day-to-day care of a child with CF commonly falls on family members who must learn to cope with both a painful prognosis and the demands of responding to the patient’s menacing symptoms, including pounding on the sufferer’s chest and back for at least thirty-five to forty minutes Introduction to the Anthropology of Health 3 at a time, two to four times a day, to dislodge mucus. Some burdens fall partic- ularly hard on the siblings of children with CF. Deana Reynold, Stuart’s mother, notes one of these burdens that he must endure: “When Carl’s sick, all the phone calls are, ‘How’s Carl?’ Everybody who sees Stuart [says], ‘How’s your brother doing?’ And all the presents. Carl gets all the presents. It has to have some kind of effect on him [Stuart].” How (and how well) do families with a child \ with CF cope? What toll does the disease take on family relations and on the emotional well-being of family members? How are siblings affected by growing up with a chronically ill brother or sister? How can health-care providers most effectively communicate with families at various stages in the natural history of CF\ progres- sion? Having previously studied children with cancer, health anthropologist Myra Bluebond-Langner (1996) set out to answer these critically important q\ uestions.

For nineteen months, in the clinic and in their homes, she repeatedly interviewed and observed families that were recruited from the patient rolls of the Cystic Fibrosis Center of St. Christopher’s Hospital for Children in Philadelphia. She also interviewed attending physicians and reviewed patients’ medical charts.

Like most anthropologists, she immersed herself in the lifeworlds of the people she was studying. Her field notes and taped interviews filled thousands \ of pages and numerous three-ring binders. In the end, after many months of data collec- tion and careful analysis, she was able to answer the key questions that moti- vated the study. Additionally—and tellingly—she was able to use her findings to develop a set of useful guidelines for physicians to use in clinical \ intervention with families with a CF sufferer. As a result, physicians now have a clearer idea of how best to communicate with families and to assist them in coping wi\ th the difficult challenges they face and the weighty burdens they must bear. Like the work of many other health anthropologists, this work by Bluebond-Langner has helped to make a positive impact in the tangled and often confusing worl\ d of health and illness. Addressing conflicts, miscommunications, and other prob- lems in doctor-patient relationships as well as patient access to high-quality, culturally appropriate health care are central issues in health anthropology. But there are many other concerns as well.

The Bone Crusher Dengue, the most prevalent mosquito-borne viral disease on earth, is found in more than one hundred countries and territories around the world, primarily in tropical and subtropical environments of Latin America, the Caribbean, and Southeast Asia, although a U.S. outbreak occurred in Hawaii in 2001. Since then, however, locally acquired cases of dengue have begun to appear in sev- eral geographic areas in the United States and researchers fear that the disease could be gaining a significant foothold on the U.S. mainland.

Current estimates are that each year fifty million to one hundred million peo- ple are infected with dengue when they are bitten by either the Aedes aegypti, the mosquito that also transmits yellow fever, or Aedes albopictus mosquitoes. 4 Chapter 1 Mosquitoes become infected when they bite people who are infected, and, in turn, they subsequently transmit the infection to other people that they bite. In Southeast Asia and in most of Latin America and the Caribbean, the disease is pandemic, meaning that it is now firmly entrenched in the population and spreading. Malaysia has been particularly hard hit; thousands of people fall vic- tim each year to this disease colloquially known—because of the fears\ ome joint pain it causes—as the “bone crusher.” Other symptoms include stomach pain, headaches, nausea and vomiting, pain behind the eyes, and body flushes. \ In a more intense and even more frightening form, known as hemorrhagic fever, the sufferer’s gums, nose, and internal organs bleed.

A number of health anthropologists have worked on preventing the spread of dengue. Karl Kendall (1998), for example, developed a strategy that\ involves studying and utilizing local health beliefs and practices in the develop\ ment of community health campaigns about dengue in El Progreso, Honduras. In Kendall’s approach, the first step in raising community awareness of effective prevention involved conducting in-depth interviews and surveys with commun\ ity members to assess what they think and believe about dengue, its routes of infection, and the strategies they use to prevent becoming sick with the dreaded disease. This information was used to frame a locally meaningful educati\ on campaign designed to raise community awareness of the insects that transmit dengue, including effective pest control measures. This culturally sensitive proj- ect proved to be effective in reducing the populations of dengue-carrying mos- quitoes, lowering rates of infection.

Sara Crabtree and colleagues (2001) built on this approach in the prevention of dengue in two communities in Malaysia. Like Kendall, Crabtree and coworkers began their work with a study of community knowledge, attitudes, and beh\ aviors related to the disease. They also conducted focus groups with four different sub- groups—women, youth, men who were heads of families, and village leaders—in an area that had not yet been hard hit by dengue. Through this research, it was found that the communities lacked much awareness of mosquito-borne disease transmission; they did not associate getting sick with being bitten by m\ osquitoes.

Consequently, while they were available, people did not make much use of mos- quito nets or spray repellents. The team then organized a set of three-day work- shops designed to train volunteers to conduct a needs assessment on how to prevent dengue in their local communities. Under the guidance of the researchers, these individuals then carried out a door-to-door survey in their local communi- ties. Researchers then worked with the needs assessment staff in translating find- ings into a strategic set of recommendations for practical, achievable activities to reduce mosquito populations. With the support of local leaders, actions based on these recommendations, such as burning accumulated rubbish, cleaning water containers, and identifying and eliminating breeding sites, were implemented to lower mosquito populations, a goal that was achieved in both participati\ ng com- munities. The health anthropologists involved in this project believed that this Introduction to the Anthropology of Health 5 success was due in large part to the initial assessment to ascertain com\ munity concerns, mobilize locally generated prevention ideas, and involve community members in all phases of the prevention initiative.

Despite the efforts described here, dengue continues to spread in the world, as do a range of old, new, and renewed diseases that were once controlled but are again spreading out of control (see chapter 6). From the fight against AIDS to the reduction of sexually transmitted diseases, health anthropologists, with their unique approach to understanding health and disease in terms of the interaction of human biology with social and cultural factors, are often on the front lines of infectious and other disease prevention as well as of the development of cul- turally and structurally appropriate and hence often more effective approaches to care. Although not all health anthropology projects are effective and success might be achieved at a much lower level of effect than would be desired, health anthropologists can point to a strong track record of making useful contributions to improving health, usually at the local level but sometimes even more broadly.

In no small part, this is because a core realization of health anthropology is that disease vulnerability, including vulnerability to dengue, “is a relationship. It is always dependent upon cultural, social, and economic factors” (Nadin\ g 2017).

Pesticide Poisoning The World Health Organization, a technical agency of the United Nations, esti\ - mates that there are more than a billion agricultural workers in the world, most in developing countries. Ethnographic research on the health of agricultural workers—specifically workers who work the fields by hands—are subject to “segregation . . . into a hierarchy of perceived ethnicity and citizenship” that pro- duces significant social and economic inequality and leads to “displa\ cement, migration, sickness, and suffering” (Holmes 2013:182). In the world inhabited by agricultural workers, their immediate supervisors, land owners, policy makers, and the wider society, the social and health inequalities suffered by agricultural workers are “considered normal, natural, and justified” (Holmes 2013:182) by ideologies of racialized biology. Rather than the consequences of unjust govern- ment policies that allow very low wages and limited occupational health \ protec- tions, exploitation by employers who are dependent on very cheap labor for their profits, and a health-care system that, by blaming workers’ culture and behavior rather than structural factors for their health problems, becomes inadvertently complicit in the functioning of a harmful social order.

Various studies have shown that one of the health problems commonly faced by agricultural workers is poisoning due to exposure to dangerous pesticides; indeed, they are the sector of society most likely to suffer health consequences from the powerful commercial poisons sprayed on food and ornamental crops to limit plant pests. Not only are those who work in agriculture at risk, but so are their spouses and children. Poisoning occurs because pesticide sprays are caught in the wind and drift into adjacent fields where people are working or into areas where 6 Chapter 1 they and their families live, because workers are sent to work in fields in which pes- ticide has recently been applied, and because workers pick up pesticides on their clothing and other possessions, including their food containers, and bri\ ng them home unaware of potential risk. Even if exposures are limited, pesticides accu- mulate in the body, so that repeated contact increases risk for health-threatening outcomes. One of the most commonly used groups of pesticides, organophos- phates (OPs), can be taken into the body through breathing, through ingestion, and through skin exposure. Organophosphates are known to damage nerves by reducing the availability of acetylcholinesterase, a necessary enzyme fou\ nd at nerve endings. Organophosphate poisoning can produce rashes, nausea and vomiting, body fatigue, loss of consciousness, shock, and even death.

One OP pesticide, chlorpyrifos, has the distinction of being a neurotoxin that has been shown to be particularly dangerous to infants and young children.

Approximately five to ten million pounds of the chemical, most of it produced by Dow AgroSciences, are applied to agricultural crops in the United States annu- ally. A review of the pesticide by Environmental Protection Agency researchers during the Obama administration led to a recommendation that, given the threat it posed to children, chlorpyrifos be banned. The review found that residues of chlorpyrifos on food crops exceed existing safety standards and that drinking water exposure to the pesticide also exceeds safe levels. With the election of the Trump administration in 2016 and the subsequent appointment of an unabash - edly probusiness and antiregulatory advocate, Scott Pruitt, to head the agency, the decision was made not to ban the pesticide. Opponents of the decisio\ n, health anthropologists among them, assert that the job of the agency, which increasingly has adopted a position of regulatory laxity, is to protect the health and safety of people, not the profits of corporations (Kolbert 2017).

Existing protections for farmworker health are limited. In 2002, for exam - ple, the Pesticide Action Network North America and a group of collaborating organizations issued a report called Fields of Poison based on data on pesti- cide poisoning collected by the California Department of Pesticide Regulation.

The report found that farmworkers face a two-sided threat from pesticides: first, the existing set of regulations designed to protect them from harmful exposure to toxic chemicals is woefully inadequate to really provide safeguards against acute pesticide exposure, and, second, even the existing laws are weakly enforced. To address this issue, Thomas Arcury, Sara Quandt, and a team of colleagues (2005) recruited a group of nine farmworker households in North Carolina and Virginia for participation in an intervention study called ¡La Familia\ !

Reducing Farmworker Pesticide Exposure, funded by the National Institute of Environmental Health Sciences. The research team conducted in-depth interviews with agricultural landowners and agricultural extension worke\ rs, com- pleted interviews on beliefs about pesticide exposure and safety among primar - ily Latino farmworkers, collected samples in the homes of farmworkers to detect the presence of OP pesticides on household furnishings, and carried out urine Introduction to the Anthropology of Health 7 tests of farmworker adults and their children to assess body metabolite levels, which reveal whether OPs are present in the bodies of study participants.

These researchers found high levels of OP metabolites, which are the by-products of OP exposure, in the members of all of the households they stud- ied, and all households had at least one member with especially high lev\ els.

Moreover, families that had carpeted homes but lacked a vacuum cleaner had higher-than-average OP metabolite levels. Bathing patterns also were linked to OP metabolite levels. As a result of their findings, this research team was able to iden- tify specific policy changes that were needed to reduce farmworker exposure to OPs, including ensuring that all rented farmworker dwellings have shower facilities and working vacuum cleaners, that all farmworker dwellings are built at a safe dis- tance from agricultural fields, and that all farmworkers receive training in pesticide risks and handling. Reflecting on the ultimate goals of their study, they conclude, Providing farmworker families (as well as all Americans) with safe and a\ ffordable housing will reduce their exposure to pesticides. This is not an instance of “blaming the victim” for exposure to pesticides, and attempting to address a systematic health disparity by educating those exposed to pesticides. Rather, it is an effort to build the capacity of farmworkers to defend themselves and to demand safe housing for their children. (Arcury et al. 2005:50) Notably, most farmworkers live in countries with far fewer resources and weaker laws to protect workers than is the case in the United States. Pesticides produced in the United States, however, are shipped around the world, and anthropologists have observed them being applied by hand by workers who had received little or no information about how deadly they can be if not han\ dled properly. For health anthropologists who work with agricultural populations, there is much work to do to help them protect themselves from occupational threats to their lives and well-being. In this instance, part of the problem is social inequality and the prevailing structure of power relations in society, such as the making and enforcing of laws that favor one social class, ethnic group, or gender over another. Indeed, health anthropologists have found that social relationships, such as those between ethnic groups, and social structures that determine access to resources and other things of value are a fundamental factor in health generally.

Although pesticide poisoning is a significant threat to the health of farmwork- ers, it is neither the only one nor the only one that has been effectively studied by health anthropologists. For example, Sarah Horton and Judith Barker (2010) have examined the issue of severe dental caries among the children of farm- workers in the Central Valley of California. They report that poor early oral health can have enduring effects both on children’s physical development, including malformation of oral arches and crooked adult teeth, and on their emotional development, as a result of social stigmatization as young adults. This research examined the role played by inadequate diet as well as other anthropogenic environmental factors in the development of what they refer to as stigmatized 8 Chapter 1 biologies. For example, these researchers present the case of Jorge, a young man who has “borne the marks of his lack of insurance as a child all his life. A star athlete and popular high school senior, Jorge feels his one social vulnerabil- ity is his stained and crooked smile” (Horton and Barker 2010:213).

Moreover, they reveal how market-based dental health insurance sys- tems—and lack of access to insurance coverage among many farmworkers—\ contribute to enduring negative health effects. For this analysis, they use Margaret Lock’s concept of local biology and recognition of the plasticity of biol- ogy to show how biology, rather than being a static or uniform phenomenon, in fact differs across groups as a result of factors like culture, diet, and the impress of a human-made environment and as consequence of differential social access to prevention care and treatment. Thus, they argue that market-based health- care systems create embodied differences between groups of people in society that both reflect and reproduce a structure of social inequality. Investigations of this sort affirm the value of a bio-sociocultural model in health anthropology.      Practical and Theoretical Contributions of Health Anthropology The cases described here suggest an answer to the question, “why have\ a health anthropology?” The answer is this: because health anthropologists, us\ ing anthro- pology’s traditional immersion methods for studying human life up clo\ se and in context, as well as the discipline’s holistic picture of the human si\ tuation, a tradi- tional disciplinary concern with understanding things from the insider’\ s point of view and flow of experience, and an applied orientation to human probl\ ems, can make an important difference in the world. Revealing the nature of this \ difference is, as noted in this chapter, one of the main goals of this book. While a primary emphasis of this book is on the practical contributions \ of health anthropology, the theoretical contributions of the discipline are equally important and guide the application of health anthropology in addressing\ par- ticular health-related issues. Theory in health anthropology addresses q\ uestions such as the following: What determines health and illness? How and why d\ o societies vary in their health-care systems, illness beliefs, and illnes\ s experiences?

What role does culture play in treatment outcome? These questions are al\ so addressed in this book.

Clarifying the Culture of Health and Illness Beyond its initial goal, a second goal of this book is a presentation of\ the fun- damental importance of culture and social relationships in health and il\ lness.

Through a review of the key ideas, concepts, methods, and theoretical fr\ ame- works that guide research and application in health anthropology, the bo\ ok Introduction to the Anthropology of Health 9 makes the case that illness and disease involve complex biosocial proces\ ses and that resolving them requires attention to a range of factors beyond biol\ ogy, including systems of belief, structures of (often unequal) social rela\ tionship, and environmental conditions. Culture is a concept that has been central to anthropology throughout its 130-or-so-year history. In the past, anthropologists tended to think of \ culture as an established pattern of influential beliefs, practices, norms, an\ d values that were shared in a social group and passed down and learned across generations to create unique configurations, the kind of differences among the ways o\ f life and temperaments of people travelers report as they visit different destinat\ ions. These differences are found not only in behavior and ideas, but also in the wa\ ys people perceive and organize their worlds, their symbols, their sense of normal\ or proper behavior, and much more. Over time, the somewhat fixed view of culture described above gave way\ to a more processual understanding of culture as an existing, discernable str\ ucture but one that is continually remade, rethought, and reinforced through social\ inter- action. Moreover, anthropologists have come to see that a vital aspect o\ f culture is its role in making life meaningful, purposeful, and understandable fo\ r people, although the meanings, purposes, and understandings people derive from t\ heir cultures differ across societies or even across sectors of the same soci\ ety (e.g., the rich vs. the poor, men vs. women, dominant vs. subordinate ethnic or\ sexual identity groups, the disabled vs. the able-bodied, doctors vs. patients)\ . Increas- ingly, in a globalizing world, where ideas, images, commercial products,\ tech- nologies, corporations, people, and diseases move rapidly across nationa\ l borders and local sites, cultures are changing. This is in turn leading to arena\ s of broadly shared behaviors and interconnectedness (e.g., global cell phone or int\ ernet use, global youth culture), sometimes referred to as the flattening of culture, as well as emergent forms of local difference that reflect the culturally specifi\ c ways global connections are mediated on the ground in different societies. Understan\ ding these sociocultural changes and the forces driving them are issues high \ on the agenda of contemporary anthropology.

Health Inequality Finally, through an examination of the issues of health inequality, such\ as the routine exposure to pesticides among farmworkers, on the one hand, and t\ o environmental degradation that causes environment-related diseases, on t\ he other, the book underlines the need for going beyond cultural or even ec\ ological models of health toward a comprehensive, biocultural health anthropology\ . Such an approach integrates biological, cultural, and social factors in build\ ing unified theoretical understandings of the origin of ill health while contributin\ g to the development of effective and equitable national health-care systems (e.g., Rylko- Bauer and Farmer 2002). In this manner, health anthropologists seek to \ be part of a collective process aimed at creating a healthier world for both hum\ anity and the biosphere and thereby prevailing over widespread patterns of hea\ lth and social injustice and environmental destruction. 10 Chapter 1 Defining Health Anthropology There is no simple definition of health anthropology because health an\ thropolo- gists are involved in so many different issues and kinds of work. Stemmi\ ng from this range, any easily crafted definition falters because it leaves ou\ t as much as it holds in. In effect, this whole book is designed to define health anth\ ropology.

Generally, however, health anthropologists are engaged in using and expanding many of anthropology’s core concepts in an effort to understand what \ sickness is; how it is understood and directly experienced and acted on by suffer\ ers, their social networks, and healers; and how health-related beliefs and practic\ es fit within and are shaped by encompassing social and cultural systems and so\ cial and environmental contexts. In this multifaceted task, health anthropologists take a page out of Shakespeare’s comedy The Merry Wives of Windsor in defining their domain of research: “Why, then the world’s mine oyster, / Wh\ ich I with sword will open.” In other words, health anthropology is concerned no\ t with a single society or with a particular health-care system but rather with h\ ealth issues throughout the whole world and even through time. Our swords, so to spea\ k, are strategies of research that are based on fieldwork and related met\ hods that are close to the experience of those being studied. Further, our armory \ includes the application of knowledge gained through research in addressing press\ ing health issues, especially among populations marginalized by existing str\ uctures of power. While recognizing the fundamental importance of biology in health and illness, health anthropologists generally go beyond seeing health as pri\ marily a biological condition by seeking to understand the social origins of dise\ ase, the cultural construction of symptoms and treatments, and the nature of inte\ ractions between biology, society, and culture. Health anthropology “seeks to consider both the cultural and biological parameters of disease” as interactin\ g biocultural processes (Joralemon 2017:11). Also, health anthropologists tend not to accept any particular health-ca\ re system, including Western biomedicine, as holding a monopoly on useful h\ ealth knowledge or effective treatment; rather, we see all health-care systems\ —from advanced nuclear medicine or laser surgery to trance-based shamanic heal\ ing or acupuncture—as cultural products, whatever their level of healing effi\ cacy and however efficacy is defined within particular healing traditions.

Culture and Biology Health anthropologists seek to understand and to help others see that he\ alth is rooted in (1) cultural conceptions, such as culturally constituted way\ s of experi- encing pain or exhibiting disease symptoms; (2) social connections, such as the type of relations that exist within the family or within society and the encompass- ing world political and economic system generally; and (3) human biolo\ gy, such as the threat of microscopic pathogens to bodily systems and the body’\ s immune responses to such threats. In pursuing these lines of inquiry, health an\ thropolo- gists are especially concerned with linking patterns of disease, confi\ gurations of Introduction to the Anthropology of Health 11 Pain and Bioculturalism Bioculturalism refers to the significant interactions that take place between biology and culture in health and illness.

Consider the issue of pain. In childbirth, a baby with a comparatively large head pushes its way through a small birth channel, a process that often produces “intense labor pains” among women giv- ing birth in the United States. While these pains are expected, they are not accepted as tolerable, and the medical administra- tion of painkillers is commonly demanded, sometimes vehemently so. In Poland, by contrast, labor pains are not only expected but also accepted, and pain- killers are not normally requested. What accounts for these differences? While pain on one level is biological, part of a bodily communication system composed of nerves that ensures urgency in limiting bodily damage (e.g., pulling one’s stray finger from the fire), health anthropologists have argued that pain expression and experience can be understood only in a cultural context. Culture teaches us how to think about, experience, and respond to the sensation of pain. Health anthropology research on the intense and chronic pain associated with temporomandibular joint dysfunction (TMD)—diseases of the joint connecting the jawbone to the skull—is instructive (Eaves et al. 2015) While not debilitating, TMD pain is aggravated by routine and otherwise enjoyable activities of daily life, including smiling, eating, laughing, and kissing. Multiple interviews with a sample of TMD sufferers in Portland, Oregon, and Tucson, Arizona, showed that they tried to minimize pain through constant vigilance to avoid flare-ups, while seeking to remain stoic in the face of pain when it occurred.

Further, participants attempted to avoid being perceived as someone who wants attention because of their pain. These goals often led to avoiding social activ- ities, hiding pain in public places, and enduring some pain to diminish being perceived as unfriendly. Rather than being biologically determined, these TMD pain management behaviors appear to reflect core values of contemporary neoliberal market-based medicine, which empha- sizes a “culture of self-help, privatization, and individualization of health” (Dutta 2016: 68). In assessing a disease, it is import- ant to consider how biology and culture interact. For example, it is likely that a devout Jew or Muslim could be made violently ill by being forced to eat pork, while consuming this meat is consid- ered very satisfying among most people in New Guinea. The same could be said of monkey brains, worms, or hamburger, depending on the cultural traditions of the people involved. Cultural beliefs and practices are very involved as well in the spread and reaction to many infectious diseases, such as sexually transmitted diseases. Disease rarely acts as an inde- pendent biological force whose health impact is everywhere the same. Rather, disease expression is shaped by cultural values, beliefs, and expectations. Cultural practices may inhibit or promote disease spread, and, conversely, disease can sig- nificantly mold culture. 12 Chapter 1 health-related beliefs and behaviors, and healing systems with cultural \ systems, social hierarchies, and biosocial relationships. Consequently, health an\ thropolo- gists have tended to look at health as a “biocultural and biosocial p\ henomenon,” based on an understanding that both physical and sociocultural environme\ nts in interaction determine the health of individuals and of whole populations\ . Central to our understanding is that while biology impacts social and cultural p\ atterns, such as the ways recent emergent infections have affected our understanding and attitudes about the world around us, the reverse is also true. Culture a\ nd social organization impact biology. To cite but one example, research has shown\ that average adult heights consistently increase with improved economic condi\ tions and decrease as economic conditions decline across time and location. Th\ is is tied to the impact of cultural and social forces on access to food and other \ resources.

In other words, “economic conditions [are] indelibly written into and\ onto the body” (Goodman 2013:365). Human biology exhibits a high degree of fl\ exibil- ity and is as much a product of culture as it is of genetics. This insig\ ht has taught anthropology that the most accurate way of thinking about humans is conc\ eiving of them as biocultural beings in which there is constant impactful interaction among our biology, our culture, and our surrounding environment. Some health anthropologists, those who call themselves critical health anthropologists (including the authors of this book), stress what they\ call a critical biocultural model, one that is especially concerned with investigating the role of social inequality in shaping health, health-related experien\ ce and behavior, and healing, issues we will explore throughout this book. What\ ever their theoretical perspective (and several alternative perspectives exi\ st within the discipline), however, health anthropologists tend to have an applied or\ ientation; they are concerned with putting their work to good use in addressing rea\ l and pressing health-related problems in diverse human communities and contex\ ts (e.g., Rylko-Bauer et al. 2006).

History of Health Anthropology The Straits Expedition Interest in health-related issues within anthropology dates to the very \ origins of the discipline as a field-oriented social science. In 1898, three Brit\ ish research- ers—W. H. R. Rivers, fellow physician C. G. Seligman, and Alfred Hadd\ on— initiated the historic Cambridge University Torres Straits (Australia)\ expedition, one of the earliest anthropological research projects. Various kinds of \ data on indigenous Australian peoples were collected during this expedition, including information on traditional healing beliefs and practices. Rivers, who so\ me see as the father of health anthropology, used data from the expedition to refu\ te the popular notion among Western physicians and other worldly observers of t\ he era that the ethnomedical practices of non-Western societies were “a \ medley of disconnected and meaningless customs” (Rivers 1927:51). Instead, he argued, ideas and practices around health and healing found in preliterate socie\ ties constitute internally coherent structures of cultural beliefs about the \ causes of disease. Now ninety years old, this perspective on healing systems around the Introduction to the Anthropology of Health 13 world has been abundantly supported by subsequent research in health ant\ hro- pology and has guided numerous examinations of the nature of the relatio\ nship of health beliefs and practices to the encompassing cultural context in \ which they are found, such as faith healing in the context of folk Christianity, as\ in the case of El Santuario de Chimayó, a Catholic healing church in New Mexico, \ shown in figure 1.1. This pattern is not limited to folk traditions but incl\ udes the dom- inant healing system, biomedicine, within modern Western society and glo\ bally.

For example, in the 1989 book The Woman in the Body: A Cultural Analysis of Reproduction, an influential text in health anthropology discussed in chapter 3, Emily Martin shows that the dominant metaphors in biomedicine for the de\ livery of babies come from the arena of industrial production. In her examinati\ on of medical textbooks, Martin found that reproduction is talked about and taught to students using analogies and concepts borrowed from factory production. \ In this biomedical cultural model of birth, (1) the doctor is portrayed as the\ manager of the laboring process, much like a factory foreman who oversees and regul\ ates the production process; (2) the uterus is portrayed as the machinery of re\ production; (3) the mother is talked about as a kind of laborer, and hence she is \ said to be “in labor” during the birthing process; and (4) the baby is the product. This way FIGURE 1.1 Crutches left behind at El Santuario de Chimayó Church in New Mexico, where pilgrims come to get “healing soil” from a hole in the church floor. Photo by Pamela Irene Erickson. 14 Chapter 1 of viewing reproduction, Martin found, is often in conflict with the v\ iews held by women who have given birth or who are about to give birth, creating t\ he potential for misunderstandings and conflicts in childbirth.

W. H. R. Rivers and Beyond In Rivers’s book on ethnomedicine, Medicine, Magic, and Religion (1927), a volume that has been called the “symbolic totem of medical anthropo\ logy” (Landy 1977:4) because it incorporates health-related issues into the \ agenda of anthropology, Rivers also maintained that non-Western ethnomedical tradi\ tions and biomedicine constitute completely separate entities. Indigenous heal\ ing, he asserted, is characterized by manipulation, using spells and other rituals, of assumed magical connections among objects and beings in the world and by\ beliefs about the actions of supernatural beings (e.g., spirits) in ca\ using and cur- ing illness. Biomedicine, by contrast, is grounded in natural laws and s\ cientific principles. Ever since, health anthropologists have grappled with understanding similarities and differences in healing systems cross-culturally. The distinctiveness of biomedicine has been intensely debated within the field. While some\ health anthropologists have accepted it as a standard by which to assess the efficacy of other healing systems, other health anthropologists have sought to show \ the following: •Biomedicine in its understandings and practices reflects its culture of origin no less than any other ethnomedicine.

•Folk healing systems around the world incorporate practices (e.g., bone setting) that are based on obser vation and practical reason as well as conceptions and protective behaviors that are believed to be derived from natural laws, such as the hot and cold properties of foods or other elements in nature, and not just on magical or religious belief.

•Many of the ideas and practices found in biomedicine are not, in fact, based solely on natural laws and scientific principles.

Pearl Katz, in her 1999 book The Scalpel’s Edge: The Culture of Surgeons (which is described in greater detail in chapter 2), portrays modern s\ urgery as an elaborate set of rituals that function to limit ambiguity, uncertainty, \ and error.

The process of “scrubbing,” for example, involves very strict beha\ viors, within precisely designated time periods, such as washing each hand in particular ways for a specified amount of time. While it is possible to significantl\ y reduce the presence of pathogens on one’s hands and arms through careful cleanin\ g, the precisely defined rules of scrubbing appear to serve also to reduce an\ xiety about not being sufficiently germ free to avoid infecting the internal organ\ s of the patient. By closely adhering to the rituals of surgery, the confidence\ doctors and nurses need to undertake a very delicate and potentially disastrous acti\ vity, such as cutting open and in some way changing a patient’s internal environ\ ment, is heightened. As a result of such studies, biomedicine is now analyzed within health anthropology as one among many ethnomedical systems around the world, Introduction to the Anthropology of Health 15 though a rather distinctive one because of its global reach, broadly rec\ ognized efficacy in handling many health problems, and ties to the internation\ al scientific community and dominant social classes worldwide. One consequence of this\ shift in perspective is that the medical anthropological perspective “\ helps us step back from medicocentrism by refusing to take [bio]medical categories and\ their various meanings as givens” (Saillant and Genest 2007:xxvii), inclu\ ding the bio- medical tendency toward biological reductionism. As a result as well, di\ versity within biomedicine is more apparent, varying in its practice and perspec\ tives across countries and within different medical specialties.

Rudolf Virchow Returning to the origin of health anthropology, Otto von Mering (1970:2\ 72) contends that the emergence of the field dates to the late 1800s when \ Rudolf Virchow, a renowned German pathologist who is often regarded as the fath\ er of social medicine because of his interest in how the distribution of he\ alth and disease mirrors the distribution of wealth and power in society, helped \ establish the first anthropological professional society in Berlin. Virchow was \ an important early influence on Franz Boas, the father of American anthropology, wh\ ile he was affiliated with the Berlin Ethnological Museum from 1883 to 1886. Virc\ how helped to lay the theoretical foundation for the approach known as criti\ cal health anthropology, which is described below.

Erwin Ackerknecht and William Caudill During the 1940s and 1950s, Erwin Ackerknecht, a German émigré, em\ erged as an important figure in the evolution of health anthropology. Using \ field accounts from anthropologists working in various societies, Ackerknecht \ sought to develop a systematic understanding of healing beliefs and practices t\ hat emphasized that (1) healing behaviors and ideas tend to reflect the \ wider cultural traditions of the society in which they develop and that (2) whatever their ability to improve the health of patients, healing systems reinforce core cultural values and structures and contribute to maintaining the status quo by controlli\ ng social conflict and deviance.

The Postwar Period After World War II, a growing number of anthropologists began to turn th\ eir attention to health-related issues, especially applied ones. Thus, the v\ ery first review of what we now call health anthropology was produced by William Caudill eight years after the end of the war and was titled “Applied Anthropo\ logy in Medicine” (Caudill 1953). Caudill’s paper marked two important d\ evelopments in the evolution of health anthropology: (1) the entry of a number of anthro- pologists after the war into international health development work and (2) the hiring of anthropologists to work in medical schools and clinical settin\ gs as teach- ers, researchers, administrators, and, in some cases, clinicians. Involvement in 16 Chapter 1 the international health field actually began during the 1930s and 1940s within the context of British colonialism—an era during which the delivery of Western health services was seen as central to a larger effort to administer and\ control indigenous peoples.

Health Anthropology and National Development Cora DuBois became the first anthropologist to hold a formal position with an international health organization when she was hired by the World Hea\ lth Organization in 1950. Within a few years, Edward Wellin at the Rockefell\ er Foundation, Benjamin Paul at the Harvard School of Public Health, and George Foster and others at the Institute for Inter-American Affairs had joined the pool of anthropologists involved in seeking to address health-related as\ pects of technological development around the world, including the negative healt\ h con- sequences of ill-planned development projects. Another set of anthropolo\ gists became involved in efforts to facilitate the delivery of biomedical care\ to people in developed nations and underdeveloped sectors of technologically advanced nations. Alexander and Dorothea Leighton, for example, became involved i\ n the Navajo-Cornell Field Health Project. This applied initiative created the social role of “health visitor,” a Navajo paramedic and health educator w\ ho acted as a “cultural broker” or community liaison between the white-dominat\ ed health- care system and the Navajo people.

The Discipline Is Born Whatever its diverse roots, as a distinct and labeled subdiscipline of a\ nthropol- ogy, health anthropology has a relatively short history that can be trac\ ed to the period after World War II (Roney 1959). Organizationally, health anthr\ opology began with the formation of the Group for Medical Anthropology in 1967, \ with Hazel Weidman, an applied anthropologist, as chair. Ultimately, this fl\ edging organization became the now quite robust Society for Medical Anthropolog\ y, a formal section of the American Anthropological Association since 1972,\ with Dorothea Leighton, a psychiatrist-anthropologist, serving as its first\ president.

As the field continued to grow and diffuse, health anthropology associ\ ations formed subsequently in other nations as well. Today, as described throug\ hout the rest of this book as well as in several others that bring together t\ he range of work done in the field (e.g., Brown 1998, Sargent and Johnson 1996\ ), health anthropology continues to grow in size and diversity of work as w\ ell as in terms of the impact of the efforts of health anthropologists on a wid\ e range of health-related issues internationally. As in any field, there have been disagree- ments and debates as well as frustration about structures that sometimes\ restrict the influence of health anthropology on health-related policy making, \ and there have been worries about how to have a bigger role in shaping public heal\ th dis- cussions to include issues of culture, social organization, and the voic\ es of socially marginalized populations. As reflected in this book, even the issue of\ what to call our field of study remains open to debate. Introduction to the Anthropology of Health 17 The Relationship of Health Anthropology to Anthropology and to Other Health-Related Disciplines Health Research and the Subfields of Anthropology Traditionally, anthropology in the United States, at least, has comprise\ d four subfields: social and cultural anthropology, biological anthropology, \ archaeol- ogy, and linguistics. In other countries, such as the United Kingdom and\ Austra- lia, the discipline has focused more narrowly on social and cultural ant\ hropology.

While some have proposed that health anthropology constitutes the fift\ h subdis- cipline of anthropology, others see it as sitting on the cusp between cu\ ltural and biological anthropology and incorporating elements of each in its unders\ tandings of health, illness, and healing. An alternative perspective places healt\ h anthro- pology on the cusp between general or theoretical anthropology and appli\ ed anthropology. In this book, as we have stressed, a primary focus is on t\ he applied side of health anthropology as a biocultural approach to addressing heal\ th issues. Health anthropology has become one of the largest topical interest areas\ beyond the four primary subfields of the discipline. One of the curren\ t debates within health anthropology is the degree to which it has had an impact i\ n shaping the ideas and orientation of the wider field of anthropology, includin\ g to what degree health anthropology has developed its own theories and to what de\ gree it has merely borrowed and applied those found elsewhere in the discipline.\ Health Anthropology and Paleopathology Health anthropology has developed an important interface with archaeology.

In that archaeology in the United States is often defined as part of s\ ociocultural anthropology or at least as part of one of the four subfields of anthropology, the bridging nature of health anthropology is particularly apparent in the field called “paleopathology,” which is the study of diseases in the pas\ t and, partic- ularly, in prehistoric times. This research is accomplished through the \ study of human fossil remains recovered through archaeological excavations. Buiks\ tra and Cook (1980) delineate four stages in the development of paleopatho\ logy: (1) the descriptive period during the nineteenth century, focusing on \ bone abnormalities; (2) the analytical period during the early twentieth ce\ ntury, when an attempt was made to interpret bone abnormalities; (3) the period be\ tween 1930 and 1970, when the field became more specialized, drawing on fields such as radiology, histology, and serology; and (4) the current phase \ beginning around 1970, when the field became considerably more interdisciplinary\ and incorporated genetic studies, including examination of microbial DNA in bone and soft tissue in order to diagnose disease in past humans. As Roberts and Manchester (1995:9) point out, one of the important lim\ ita- tions of paleoanthropology is that the populations being studied are lon\ g dead, and consequently the number of cases being studied from any population are limited, a mere “sample of a sample of a sample.” As a result, it is difficult to generalize to the whole population from which the cases are drawn. 18 Chapter 1 Applied Anthropology in Action Health anthropology straddles the line between theoretical and applied anthro- pology. Applied anthropology is the appli- cation of anthropological theories, con- cepts, and methods to solving problems in the world. Applied anthropologists work in many different areas, from A for aging, such as solving problems in the isolation aging people often feel in Western soci- ety, to Z for zoos, as seen in work done to determine how to use zoos to edu- cate visitors about pressing environmen- tal issues. While it is sometimes asserted that applied anthropology grew out of theoretical anthropology, the reverse is in fact the case. In the United States, for example, some of the individuals who first found employment as anthropolo- gists worked for the Bureau of American Ethnology (BAE). The BAE was set up in 1879 as a policy research arm of the federal government to provide research needed to inform congressional decisions about the American Indian population.

The bureau’s first director, W. J. McGee, proposed that the organization focus on what he called “applied ethnology,” which led to a series of descriptive reports that were prepared for policy makers. Despite this fact, there have been strong tensions at times between applied and theoretical anthropology. Some theoretical anthro- pologists identify the discipline’s mission as understanding diverse pathways in human social life. They assert that to use anthropology to formulate planned social change violates two basic disciplinary principles: cultural relativism, which pro- scribes judging any given society by the values of any other, and avoidance of research bias, which includes, among other concerns, the scientific standard of minimizing opportunities for data contami- nation because of the value commitments of the researcher. Both of these principles suggest that intervention is, by definition, not anthropology. Applied anthropologists counter that science does not exist in a social vacuum and that its fundamental purpose is to apply its findings to solv- ing human problems and improving the quality of human life. Because we live in a world of cultural contact and resulting social change that often leads to pressing problems and extensive human suffer - ing, applied anthropologists feel obliged to apply their skills and understandings to solve real-world challenges. In recent years, these divisions have begun to break down, and older animosities about what is the proper role of anthropologists in society have begun to fade into history. Many nurses have found anthropology and specifically health anthropology to be of great utility in their work. Consequently, numerous undergraduate nursing pro- grams require their students to take a course in cultural anthropology, and many nursing schools now teach courses in health anthropology and related subjects.

Indeed, many of the people teaching these courses are nurses who have obtained graduate degrees in health anthropology.

Some anthropologists have argued that, in contrast to biomedical physicians, who tend to be “disease oriented,” nurses are inclined to be more “person oriented.” With this orientation, developing a health anthropology perspective appears as a useful and practical one for many nurses. A specific example of one type of work that applied health anthropologists Introduction to the Anthropology of Health 19 Despite this shortcoming, paleopathology has much to teach us about diseases and related health problems of antiquity, including congenital \ defects, traumatic injuries, infectious diseases, metabolic and nutritional disorders, degenerative diseases, circulatory problems, caries, and even cancer. Fo\ r exam- ple, bone spurs in the knees, toes, and spines of ancient Mesoamerican w\ omen strongly suggest that they spent long hours grinding maize to make flo\ ur. Paleopathology can also contribute to the solving of medical mysteries. \ A case in point is the cause of death of Pharaoh Tutankhamun, more popul\ arly known as King Tut, a relatively minor ruler historically but today the b\ est-known member of ancient Egypt’s dynastic line. On November 4, 1922, archaeo\ logists discovered and began excavating King Tut’s thirty-three-hundred-year-\ old sub- terranean royal burial tomb in Valley of the Kings, the royal necropolis\ of Egypt’s eighteenth through twentieth dynasties, located on the west bank of the Nile River opposite the modern city of Luxor. The richness of the funerary ar\ tifacts in the tomb, and the discovery of the pharaoh’s mummy, led to extensi\ ve press coverage and the rapid rise of King Tut in the popular imagination world\ wide.

A subsequent autopsy of the Tutankhamun mummy concluded that the pharaoh\ had died around the age of nineteen years. Speculation soon developed ab\ out the cause of death of the young ruler. Initial conjecture focused on the king’s skull because of a small dense spot, suggesting the possibility of brain traum\ a inflicted by a murderous blow to the back of the head. According to Bob Brier, aut\ hor of the popular book The Murder of Tutankhamen (1998), in light of the “violent, unstable times Tutankhamun ruled in, and [based on] forensic evidence \ . . . mur- der and intrigue emerged as the best explanation” (xix) of the phar\ aoh’s untimely do is seen in the efforts of Dan Small (2016) at Insite, a medically defensi- ble but culturally controversial program located in Vancouver in western Canada.

Insite is a legal, medically supervised facility for the injection of illicit drugs that is designed to reduce the potential harm (e.g., drug overdose) associated with drug use. Small’s work began with helping to identify cultural barriers to implementing this controversial health- care program. Once barriers were deter - mined, a cultural initiative was developed to shift dominant social narratives about addiction that often create barriers to programs designed to address the health needs of a socially denigrated population.

Clients of Insite are able to choose their injection equipment from on-hand sterile supplies and report which drug they are injecting. This information assists with implementing individualized emergency intervention if required. Drugs are not provided at the facility; users must bring their own. Participants are assigned to one of twelve injection booths, each of which contains a stainless-steel counter - top and mirror to facilitate the user having a clear view of their chosen point of injec- tion. There is also a nursing station for medical support staff, who provide crisis intervention, referrals to treatment, addic- tion counseling, detox, and supported housing referral. Rather than just study health risk among injection drug users, Small’s work, as an advocate of harm reduction, focuses on lowering risk in a nonjudgmental, rapport-building manner. 20 Chapter 1 death. Additionally, based on several peculiar features of statues, pain\ tings, and other ancient depictions of King Tut and members of his family (e.g., s\ uggesting androgynous characteristics among males as well as notably elongated hea\ ds and fingers), numerous speculative reports have been published about vari\ ous diseases allegedly suffered by King Tut. Among these are Marfan syndrome, a genet\ ic disorder that leads to above-average height, long slender limbs, and lon\ g fingers and toes; Wilson-Turner X-linked mental retardation syndrome, a congenital disease characterized by mental disabilities, childhood obesity, and enl\ arged male breasts; and Fröhlich syndrome, a disease caused by tumors of the hyp\ othalamus that produces mental retardation and retarded sexual development. In par\ t to test these various hypotheses, Zahi Hawass, an archaeologist and Egypt’s s\ ecretary general of the Supreme Council of Antiquities, led an international team that carried out a set of now widely publicized anthropological, paleopatholo\ gical, radiological, and genetic analyses of a group of mummies as part of the \ King Tutankhamun Family Project. While discounting various earlier hypotheses about King Tut’s death, this study concluded that a likely cause of d\ eath was the occurrence of multiple health problems including malaria (based on fi\ ndings of ancient malaria DNA in King Tut’s mummy), juvenile aseptic bone necr\ osis or Köhler disease II (involving loss of blood to the king’s left foot, causing bone death and collapse), and a fracture of his left femur that was unhealed\ at the time of death. King Tut’s death, in other words, was a consequence neither\ of intrigue and ancient rivalry nor of a rare and disforming genetic disorder, but r\ ather was caused by the adverse interaction of several diseases and trauma-induced\ infec- tion (Hawass et  al. 2010). Most important, this study suggested the possibility that malaria, alone and in interaction with other diseases and condition\ s, was an important factor in the health of all sectors of ancient Egyptian societ\ y.

Health Anthropology and Epidemiology The AIDS Connection Beyond its ties to subfields within anthropology, health anthropology \ also has an important connection with epidemiology, a discipline concerned wi\ th the patterns and spread of disease, including containing outbreaks of di\ sease.

At the U.S. Centers for Disease Control and Prevention (CDC), a branch\ of the national Public Health Service, scientists monitor the appearance an\ d spread of disease all over the country and beyond. In the AIDS epidemic, for example, CDC researchers attempted to understand what was causing the disease, how it was spread, and how it could be stopped. There has been a long but in some ways not always deep collaboration between epidemiologists and health anthropolo- gists. Well over three hundred health anthropologists, for example, have\ worked on some aspect of the global AIDS epidemic, often in close partnership w\ ith epidemiologists and other researchers and interventionists (Bolton and Orozco 1994), although far fewer work on the epidemic today. In this work, as \ Patricia Whelehan notes in her 2009 book The Anthropology of AIDS: A Global Perspec- tive, health anthropologists have addressed various bio-sociocultural factor\ s, ethical issues, cultural factors and social reactions, gender roles and \ relations, Introduction to the Anthropology of Health 21 sociopolitical and socioeconomic influences, and transnational and int\ ergroup differences in the nature of the impact and range of responses that have\ developed to the pandemic. Health anthropologists have played various roles in the global AIDS pandemic. To cite one example, they have worked closely with outreach workers who locate and recruit hard-to-reach at-risk individuals, such a\ s injection drug users, for interviews by the anthropologists on patterns of HIV ris\ k and/ or for participation in prevention interventions. Research of this sort \ has led to discoveries by health anthropologists and their colleagues of a range of\ behaviors beyond direct syringe sharing that can spread the virus that causes AIDS\ as well as sexual risk associated with injected and noninjected drug use (such \ as the use of crack cocaine). In addition, health anthropologists were involved in\ identifying social and behavior contexts in which risky behavior is most frequent, a\ ssessing the role of social networks in the spread of HIV infection and the importance of exposure to violence in risk behavior, and have played key roles in p\ revention research on syringe exchange. Broader social and political issues have also been addressed by anthropo\ lo- gists in the AIDS pandemic. In her work in South Africa, for example, Ida Susser (2009) focused on women’s avenues of hope, sources of resilience, and mount- ing community activism in response to the toll of AIDS. Central to Susse\ r’s objective was the development of a detailed account of women’s on-the\ -ground responses to the entwined effects of disease, gender discrimination, and\ the world economic system through which wealthy countries promote deprivation, soc\ ial suffering, and the spread of disease in poorer nations. Notably, Melissa Parker (2003:179), who studied unsafe sex among gay-identified men in the back rooms of pubs, clubs, and saunas in Lon\ don, has argued that anthropologists should “draw upon their ethnographic expe\ rtise and help to design interventions which target people and places with the\ explicit intention of promoting social change and saving lives.” Health anthropologists who continue to work in the HIV/AIDS epidemic have a strong focus on treatment and its impact on populations.

Cultural Epidemiology In his book Epidemiology and Culture, James Trostle (2005), an anthropologist long concerned with building collaboration between epidemiology and anthro- pology, argued for the creation of a “cultural epidemiology” that \ would integrate the anthropological concept of culture into the set of explanatory varia\ bles used by epidemiologists to explain disease. Cultural beliefs and practices ab\ out con- dom use, for example, contributed to the spread of HIV infection. Becaus\ e many people link condom use to casual intercourse with people other than thei\ r main partner, at times it has been difficult to convince them to use condom\ s in their primary relationships. Another example of how culture impacted HIV preve\ ntion was provided by Alexander Rödlach (2006) in his study of AIDS-relat\ ed beliefs in Zimbabwe in sub-Saharan Africa. Rödlach found that many people in Zim\ babwe wondered if the disease was spread either by sorcery or because of a con\ spiracy, such as a plot by the U.S. government to punish people of color. Importa\ ntly, he argued that studying such beliefs, which are widespread in the world,\ is not an 22 Chapter 1 attempt to contribute to the construction of an exotic other (i.e., viewing people who are culturally different as bizarre or less intelligent). Rather, h\ e emphasized that developing a better understanding of cultural beliefs about the nat\ ure and spread of AIDS “yields theoretical insights into how people explain a\ nd react to health problems, [which] in turn benefits health programs” (2006:1\ 3). Sorcery and conspiracy beliefs, he notes, are prevalent in social groups that ha\ ve endured suffering, through poverty, discrimination, and disempowerment, at the h\ ands of outsiders. Such beliefs, in other words, are culturally constituted idioms of dis- tress that express the harmful experience of feeling helpless and unable to c\ ontrol much about one’s life (and hence suspecting a nefarious outside agen\ t as the source of one’s painful lived experiences). A similar pattern has be\ en described in accounting for the conspiracy beliefs that emerged during the 2014–20\ 16 Ebola epidemic (Ayegbusi et al. 2016, Ngade et al. 2017). Health anthropologists use the term idioms of distress to describe the culturally specific and symbolically rich frameworks of understanding through which people both experience and articu- late social discontent and suffering. In addition, they have come to rec\ ognize that even standard biomedical terms such as diabetes can come to be used popu\ larly as idioms of distress when they refer to health conditions that reflect health and social disparities and express the lived experience of social suffering.\ Health Transitions Within epidemiology, the term health transition is used to label broad changes that have occurred within particular historic phases in the health profi\ le of populations and the primary causes of mortality. The first health tran\ sition in human history began about ten thousand years ago when the development of\ agricultural modes of food production and more sedentary communities led to a marked increase in acute infectious diseases (often involving the adaptation of the disease-causing pathogens of domesticated animals such as cattle to huma\ n hosts and resulting in human epidemics). A second health transition occurred \ between the late eighteenth and early twentieth centuries with the rise of indus\ trial econ- omies. This economic and social transformation involved the restructuring of environments, industrial pollution of the air, water, and land, and chan\ ges in life conditions. These sweeping changes contributed to the growing impor\ tance of chronic diseases such as heart disease, stroke, cancer, and diabetes \ and what are termed behavior problems, such as substance abuse. Ultimately, especially as a result of public health measures supported eventually by biomedical in\ terven- tions, a drop also occurred in many developed nations in rates of lethal\ infectious diseases as well. However, one effect of the second health transition is that poorer countries now suffer from what has been called the “triple burden”\ of acute disease, such as diarrheal disease; chronic disease, such as cancer; and\ behavioral pathology, such as the global spread of illicit drug injection. At the s\ ame time, health-care systems have been changing. One force pushing such changes h\ as been the imposition of what are called neoliberal reforms by international lender institutions (i.e., banks that loan money for development to poorer cou\ ntries), such as the World Bank. In poorer nations, such as Mongolia, as health a\ nthro- pologist Craig Janes (Janes and Chuluundorj 2004) found during his res\ earch Introduction to the Anthropology of Health 23 there, lender-endorsed steep cuts in government investment in the health\ sector and the transformation of health services from a government-provided ben\ efit to a purchasable commodity resulted in a significant drop in the quality \ and quan- tity of health services available in rural areas while restricting acces\ s to services that were still in operation. Janes discovered that women in particular \ were vul- nerable to these changes, leading to increasing rates of both poor repro\ ductive health and maternal mortality. Similar negative health effects of what has been called structural adjustment (i.e., changes in government policies and structures demanded by international development loan providers such as the World B\ ank and International Monetary Fund) have been described by health anthropo\ lo- gists working in various locations around the world. As Mark Nichter (2008) indicates in his book Global Health: Why Cultural Perceptions, Social Represen- tations, and Biopolitics Matter, structural adjustment has led to a proliferation of service-providing nongovernment organizations (NGOs) in underdevelo\ ped nations. One result is that in places such as Haiti there are multiple, uncoordi- nated, and competing health programs governed by the dictates of foreign\ fund- ing institutions. This change has contributed “to the undoing of gove\ rnment services” (Nichter 2008:139) and the weakening of governments in de\ veloping nations, pushing them, as has occurred in places such as Haiti, Peru, El\ Salvador, and several countries in southern Africa, beyond the ability to meet the\ basic public health needs of their citizens (M. Singer 2010a, Smith-Nonini 20\ 10).

A study that reviewed a decade of the effects of structural adjustment p\ olicies in eight Latin American countries, for example, found that, in an effort by\ lender banks to make interest from the development loans they had made, health \ and social expenditures designed to meet human needs were cut drastically, l\ eading to ever-widening disparities between the health and well-being of the ri\ ch and that of the poor (Petras and Vieux 1992). Many of the failures of neoliberal “development,” in terms of human suffering and the promotion of po\ verty, in what amounts to a form of economic neocolonialism, are now acknowledged \ by some leaders of the World Bank. In the last decades of the twentieth century, a third health transition \ began, and it continues into the twenty-first century. This transition involves the rapid appearance and global spread of new infectious diseases such as HIV/AIDS, SARS, Ebola, Zika, and avian influenza and the development of new levels of virulence and drug resistance in older infectious diseases such as tuberculosis. In the third health transition “poverty combines with urbanization and the dissolution of\ traditional family structures to intensify [health] challenges” from infectious agents, processes of globalization (e.g., rapid travel and the global shipment of commodities) enable the brisk movement of infectious diseases around the world, and microbia\ l adap- tation to medicines weakens the effectiveness of drugs like antibiotics \ to control infectious diseases (Barrett 2010). At the same time, adverse synergis\ tic interaction among diseases (infectious, chronic, behavioral) has promoted the appearance and adverse health impact of disease “syndemics” that further increase\ the total health burden of affected populations (Bulled and Singer 2010, M. Singer 2010b, M.

Singer et  al. 2017). These factors are significantly shaping contemporary globa\ l health and appear likely to do so well into the future. 24 Chapter 1 Illness and Help-Seeking Behavior One of the important issues on which health anthropologists have focused\ is how local sociocultural factors come into play in “monitoring the body, recog- nizing and interpreting symptoms, and taking remedial action . . . to rectify the perceived abnormality” as well as “adherence to therapeutic advice\ , changes in treatment regimens [e.g., switching healers], and evaluation [and reevaluation over time] of therapeutic efficacy and outcome” (Christakis et \ al. 1994:277).

In short, health anthropologists are interested in the ways that culture\ helps to shape the “illness behavior patterns,” including help-seeking acti\ ons, found in a society. Of note, illness behavior is mediated by a sufferer’s subj\ ective inter- pretations of the meaning of experienced symptoms. However, these interpre- tations are not solely idiosyncratic but rather are influenced by wide\ r cultural understandings of illness and the comments and actions of the sufferer’\ s social network. For example, in “several areas of Africa where malaria is en\ demic, sei- zures [which in biomedicine are recognized as symptoms of malaria infect\ ion] are viewed as a ‘folk illness’ largely unrelated to malaria and are of\ ten attributed to supernatural causes” (Nichter 2008:74). Illness behavior is impacte\ d by various factors, including gender (thus men and women often “get sick” di\ fferently) and socioeconomic status. Also, illness behavior in a society is not static;\ as a society changes, illness behaviors change as well, including patterns of use of health services. The global distribution of pharmaceutical drugs, for example, \ has con- tributed to the use of these commercial laboratory remedies in ways that go far beyond their intended purposes and patterns of use, such as crushing ant\ ibiotic capsules and applying them to wounds or the emergence of local healers w\ ho administer individual antibiotic injections. Documenting and assessing e\ mergent patterns of illness behavior and their causes is a role that health anth\ ropologists are playing in the realm of epidemiology. More broadly, health anthropol\ ogists seek to move beyond the examination of individual suffering to social su\ ffering.

Health Anthropology and Public Health Closely related to epidemiology is the discipline of public health, a fi\ eld that is concerned with assessing and improving the quality of health of the g\ eneral populations as well as that of especially vulnerable and at-risk subgrou\ ps therein.

Health anthropologists contributed to public health by ethnographically \ exam- ining disease-promoting behaviors in social context. As social scientists who attempt to “elucidate how and why people do what they do,” health \ anthropolo- gists have been able to contribute to disease prevention and control (B\ rown et al.

1996:198). Failure to understand the factors that shape the behavioral \ decisions people make, the frames of understanding they bring into play, and the i\ nfluence of social relationships on their actions is a contributor to the disappo\ intments of public health interventions. Another role for health anthropologists inv\ olves the issue of public trust in public health messages. While public health wor\ kers are motivated by a commitment to improving public well-being, the population\ s they seek to assist may not share their enthusiasm or trust their intentions.\ Resistance to public health measures, for example, has been described for populatio\ ns at risk Introduction to the Anthropology of Health 25 for polio vaccination and Ebola infection. In the case of Ebola, people \ in some locales even came to question whether public health workers were bringin\ g the potentially fatal disease rather than trying to curtail it (Cohn and Ku\ talek 2016).

This pattern underlines the importance of ethnographic research on the d\ rivers of fear and public health distrust in the development of grounded unders\ tandings of public responses to and following epidemic outbreaks. Health anthropo\ logy research on the drivers of public distrust informs efforts to improve pu\ blic health communication, the nature of public health messages, the public presenta\ tion of public health interventions, and the role of community involvement in\ the context of infectious disease epidemics (Abramowitz 2014). A number of methodological and conceptual developments in public health \ in recent years have created new opportunities for health anthropology t\ o play a part in public health discussions and interventions. Among these new dev\ elop- ments are (1) the growing public health and medical concern with healt\ h inequi- ties, (2) the increasingly recognized need to enhance the cultural com\ petence of health-care providers, (3) the emergence and growing influence of th\ e communi- ty-based participatory research model, (4) the diffusion of and increa\ sing funder emphasis on evidence-based interventions in public health, (5) the mou\ nting demand for translational research that allows the findings and knowled\ ge pro- duced by health-related studies to shape health intervention efforts, and (6) the spiraling interest in what have come to be called complementary and alte\ rnative medicines. At the same time, a research method developed within anthropo\ l- ogy—rapid ethnographic assessment—has spread into public health, c\ reating additional opportunities for health anthropology to have an impact on he\ alth issues. Each of these increasingly important arenas of public concern in\ which health anthropology directly or indirectly has played a role is describe\ d next.

Health Inequity or Disparity Health inequity or disparity refers to the significant differences in the health profiles (i.e., the distribution of diseases and wellness) across hu\ man populations, social strata such as social classes, or other segments of the populatio\ n, such as rural areas compared to urban settings. Additionally, health disparities\ research- ers are concerned with why disparities in health exist. In the United St\ ates, for example, as Grace Budrys (2003:39), observes in Unequal Health: How Inequal- ity Contributes to Health and Illness, from a health standpoint “being at the top of the [social class] heap is a lot better than being on the bottom. \ .  .  . There has been an explosion of research indicating that social class is a powe\ rful, and arguably the most powerful, predictor of health.” Critical health anthropolo- gists, for example, have examined the roles that economic structures (e\ .g., wage constraints) and health insurance companies (e.g., ability to pay for \ coverage vs.

actual medical need) play in limiting people’s ability to make healt\ hy choices in their lives (Fletcher 2017). The nature and importance of health inequities will be examined in great\ er detail in chapter 4. Suffice it to note here that it is an important h\ ealth arena in which a number of health anthropologists have become quite active, su\ ch as Sabina Rashid, who works among the poor of Dhaka, Bangladesh (figure \ 1.2). 26 Chapter 1 Community-Based Participatory Research There are various approaches to research on health issues in specific \ populations and communities. In the “unilateral research model,” researchers b\ ased at univer- sities or research centers design a research project based on their unde\ rstanding of the key issues and questions. The research agenda in this approach is\ almost completely if not completely determined by the researchers in terms of t\ heir conceptions and interests. After a project is largely designed, the rese\ archers may contact and subcontract with a community organization to recruit par\ tici- pants from the community who will be interviewed in the planned study. O\ ften strapped for funding, community organizations accept such subcontracts even though they may at the same time resent not having much voice in planning the study, including a say in what from the community’s perspective a\ re the key health issues in need of research. Another approach to research is c\ alled the “collaborative model.” In this approach, while researchers initially conceptualize a study, they then contact one or more organizations based in the commun\ ity of concern and invite them to participate in fleshing out the details \ of the study.

While the community organization(s) participates at some level in the study, the bulk of project direction, decision making, and funding is still centere\ d in the university or research institute. Both unilateral and collaborative rese\ arch projects are very common and can be found on most university campuses, often fund\ ed by federal research grants or private health foundations. As contrasted with both of these approaches to research, community-based\ participatory research (CBPR) is based on a full partnership between r\ esearchers and community representatives and organizations, from project conception\ to FIGURE 1.2 Children from poor families in an urban slum in Dhaka, Bangladesh. Photo by Sabina Faiz Rashid. Introduction to the Anthropology of Health 27 completion, including publication of findings. Community-based partici\ patory research grew out of recognition that traditional population-based biome\ dical research methods lack authentic community involvement and often result in community alienation from research and researchers. In some cases, researchers have come to be defined as exploiters of communities rather than as th\ eir natural allies. Consequently, in CBPR-guided projects, the community plays a key\ role in setting the research agenda. In this, communities are guided by their\ pressing need for specific health-related knowledge, which can be used in addre\ ssing com- munity health problems and in making ongoing decisions about the directi\ on of the research. As the concept of CBPR has developed and its value recogni\ zed, various efforts have been made to establish guidelines for successful an\ d mutually satisfying participatory research projects. Health anthropologists have contributed to the development of this alter\ na- tive orientation to research. For example, the Institute for Community R\ esearch in Hartford, Connecticut, a community-based organization that has been led by anthropologists since its founding, established the Youth Action Rese\ arch Institute to promote the use of a participatory action research model am\ ong youth. Central to the institute’s work have been projects that involve minority youth in ethnographic research on issues of concern to the youth (e.g., AIDS and substance abuse), including the primary health and social problems face\ d by their communities. Anthropologists train youth in ethnographic methods and help them identify problems for action research. The goals of this proje\ ct were personal growth among the youth participants, the development of positiv\ e peer norms, and the assessment of community health needs.

Diffused Evidence-Based Intervention There has been a strong effort in recent years to accelerate the movemen\ t of scientifically proven (i.e., evidence-based) intervention models, su\ ch as train- ing programs to assist people in avoiding communicable diseases. Rather \ than funding organizations to implement intervention models that have not been evaluated, funder institutions, such as the CDC, began emphasizing the u\ se of models that have proven to be effective. The CDC’s Diffusing Effectiv\ e Behav- ioral Interventions project, for example, has helped implement eighteen \ different research-based infectious disease prevention models through community-ba\ sed organizations, health departments, and other prevention providers across\ the United States. These were designed for specific populations, such as i\ njection drug users, sexual and romantic partners of injection drug users, men wh\ o have sex with men, heterosexuals at high risk, people living with infect\ ion, and homeless and runaway adolescents. To prepare community organizations to suc- cessfully implement these intervention models in their respective commun\ ities, the researchers or those they have trained are called in to provide guid\ ance and technical assistance to the frontline people who would use the models in\ day-to- day prevention work.

Translational Research Translational research is a specialized type of research carried out wit\ h the inten- tion of improving the flow of knowledge from research into action in p\ ublic 28 Chapter 1 health or some other arena of social intervention. Health practitioners \ and policy advocates, for example, have complained that the findings of behaviora\ l research are slow in finding their way to public prevention efforts. For exampl\ e, anthro- pologists and others who conduct ethnographic research with injection dr\ ug users have observed that they engage in a number of behaviors during the\ con- sumption of drugs that might lead to infection. One of these behaviors i\ nvolves several drug users pooling their money to purchase a packet of an illici\ t drug, such as heroin or cocaine, and then mixing it with water, using one of t\ he partic- ipant’s syringes and the unit gauge on its barrel to measure the righ\ t amount of water to allow an equal distribution of the dissolved drug. If the syrin\ ge that is used for this purpose contains an infectious agent, then the virus may b\ e flushed into the container (such as a bottle cap) that is being used for drug \ mixing and drawn up by all the individuals who are sharing the drugs from that container.

In this way, all these individuals may be exposed to infection. An exami\ nation of the messages given by prevention programs to drug injectors to protect t\ hem- selves, however, often urges them only not to “share needles.” Bec\ ause individ- uals who share drugs may never share a needle, they may falsely believe \ that they are protected from infection when in fact other behaviors in the drug pr\ eparation and use process are causing disease transmission. As a result of examples like this, those involved in translation researc\ h have urged social scientists not only to publish their findings in professi\ onal journals, most of which are not widely read outside of academic and research setti\ ngs, but also to take specific steps to ensure that their research is readi\ ly accessible to, relevant for, and understood by those who work in prevention program\ s or who make health policy decisions. A fundamental issue facing the health inter- vention is “how to translate the research findings for more widespr\ ead practice” (Sloboda 1998:203). The need for readily accessible and usable knowled\ ge is particularly great in intervention efforts targeted to populations that \ are harder to reach and harder to retain in public health programs, a task that has\ been taken on by a number of health anthropologists. At the same time, interv\ entions models proven effective at the local level, if they are to have a signifi\ cant impact on disease, must be scaled up beyond the pilot level. For example, with \ regard to AIDS prevention programs in Africa, Binswanger (2000:2173) argues, “\ In most of Africa, there are examples of excellent HIV/AIDS prevention, mitigati\ on, and care projects. These projects reach only a small fraction of the populat\ ion how- ever. Like expensive boutiques, they are only available to a lucky few.”\ This too is a type of work that is well suited to the skills and interests of hea\ lth anthropol- ogists because “translating recent research advances into communities\ at risk . . .

requires thoughtful adaptation to meet the needs of the community effect\ ively with emphasis on social, economic, and cultural heterogeneities” (McGarvey 2009:242). It also requires creativity and a keen awareness of the cultural life and social context of target populations (figure 1.3).

Complementary and Alternative Medicine There has been a fairly dramatic shift in recent years in the way policy\ makers, health-care providers, and the general public view healing systems beyon\ d the dominant biomedical approach. One indication of this change is the remak\ ing Introduction to the Anthropology of Health 29 of the American pharmacy. Today the shelves of the average major chain p\ har- macy in the United States and Australia (although not everywhere in the\ world; see figure 1.4) are filled with over-the-counter alternative medici\ nes, such as St.

John’s wort, echinacea, and black cohosh, that in the past could have\ been found only in specialty health food stores or alternative markets. Moreover, i\ n 1992 the U.S. Congress established the Office of Alternative Medicine, which in\ 1999 became the National Center for Complementary and Alternative Medicine, one of t\ he twenty-seven research institutes and centers that make up the National I\ nstitutes of Health. The mission of the center is to promote scientific exploration\ of promising nonbiomedical healing practices and to disseminate research-based inform\ ation on these practices to the public and health professionals. While some have \ argued that the new interest in complementary and alternative healing systems is dri\ ven, at least in part, by a desire to subordinate them to the dominant biomedical syst\ em (Baer 2004), there clearly has been a significant change in the way they ar\ e viewed and their place in Western societies if not globally. We will return to the \ issue of comple- mentary and alternative medicine later in the book as we explore alterna\ tive health approaches. Here, suffice it to say that the rise in interest in compl\ ementary and alternative medicine rests on and grew out of a long history of anthropological study of nonbiomedical healers and their approaches to the treatment of illnes\ s.

Rapid Ethnographic Assessment The rapid ethnographic assessment approach to research, which has now be\ en adopted by health promotion institutions around the globe, was first f\ ully FIGURE 1.3 AIDS educators in Havana, Cuba. Photo by G. Derrick Hodge. 30 Chapter 1 described in the late 1980s and early 1990s by anthropologists Susan Scr\ imshaw and Elena Hurtado. Rapid ethnographic assessment is designed to bridge t\ he gap between science and public health practice and policy by allowing th\ e swift movement from community-based research on health or other pressing socia\ l issues to interventions based on research findings. While ethnographic\ research traditionally was both a labor- and time-intensive approach, Scrimshaw sought a methodology that would take advantage of close-up ethnographic insight in a community of concern without requiring the customary year or more of soc\ ial immersion and extensive documentation of behaviors and events characteri\ stic of traditional anthropological fieldwork. Rapid approaches do this by \ prepar- ing researchers to build on existing knowledge of a target community and\ to implement several strategies for the rapid development of rapport, such \ as the use of local staff to collect information in their own communities and c\ ollabo- ration with local community organizations, in the assembly of highly foc\ used data on very specific issues and problems. For example, in Project RAR\ E (Rapid Assessment, Response, and Evaluation), anthropologists and other resear\ chers used focus groups, quick-intercept interviewing, concentrated field observa- tion, and social mapping to identify and describe gaps in the existing a\ rray of AIDS prevention programs and services in several dozen cities across the United States. In the Hartford RARE project, for example, the research team, which FIGURE 1.4 Modern pharmacy in Cuba lacks the many over-the-counter commercial “folk medicines” now found in U.S. pharmacies. Photo by G. Derrick Hodge. Introduction to the Anthropology of Health 31 consisted of people from the local community led by several community-ba\ sed health anthropologists, found that late-night (midnight to 4:00 a.m.) \ sexual and drug use behavior was not being addressed by existing AIDS prevention ef\ forts, resulting in a continued spread of HIV in the local population. As a res\ ult of the project, the city health department began to require late-night preventi\ on efforts by some of the organizations that it funded to prevent the spread of AIDS in the city. The value of rapid research methods has been recognized in oth\ er fields as well, leading to the development of other types of accelerated assess\ ment and evaluation models, such as rural rapid appraisal, rapid epidemiology, ra\ pid disas- ter assessment, and rapid assessment of biomedical conditions. All these\ present emergent arenas of employment for health anthropologists.

Health Anthropology and Bioethics Bioethics emerged as a new academic field during the 1970s and has qui\ ckly become an important force in science and medicine and, through the setti\ ng of health-related social policies and the rise of institutional review boar\ ds (IRBs), in health anthropology as well. The term bioethics can be defined as a branch of the field of ethics that is concerned with the establishment and application of standards and principles by which human actions within the arenas of hea\ lth care, health-related decision making, and health research can be judged morall\ y right or wrong. Many hospitals, for example, employ experts on bioethics to pr\ ovide consultation on the treatment of terminally ill patients and to inform decision making regarding issues such as organ transplant, abortion, euthanasia, \ in vitro fertilization, and the allocation of scarce clinical resources. As Evere\ tt (2006:46– 47) points out, while it is likely that, because of the kinds of research they do, health anthropologists would have something important to offer, “they\ have found it especially difficult to find a place within bioethics debat\ es” that tend to be dominated by the fields of philosophy, law, and biomedicine. Health\ anthro- pologists, in fact, have sometimes been critical of bioethics because of\ a lack of sensitivity to cultural differences. Rayna Rapp (2000a:44), a health a\ nthropolo- gist who does ethnographic research on genetic counseling, for example, argues that bioethics is “self-confidently unaware of its own sociocultura\ l context” and fails to consider whether the standards it develops reflect the values\ of non-West- ern populations. Thus, bioethics has emphasized the importance of respec\ ting individual autonomy, free will, and self-determination and thus has oppo\ sed forc- ing patients or research participants to do things against their will or\ without their full consent. The problem, health anthropologists point out, is that the\ values emphasized in bioethics reflect the Western celebration of individuali\ sm, a moral stance that is not shared by cultural systems that emphasize collectivis\ t models or rigid social hierarchies. The narrow application of Western ethical s\ tandards without sensitivity to alternative norms may be construed as ethical imp\ erialism. Moreover, bioethics has been used in the effort to set standards for eth\ ical research in light of a past history of gross violations of the rights of\ human sub- jects in research. All universities and research centers now have IRBs t\ hat apply standards established for medical research to all forms of research invo\ lving 32 Chapter 1 human subjects. According to these standards, all research that has pote\ ntial risks for human participants, including research by health anthropologists, mu\ st be reviewed and approved by an IRB. A number of anthropologists have questi\ oned the appropriateness of IRB review of ethnographic research on the grounds that it commonly involves the misapplication of standards that were establish\ ed for biomedical and experimental research where life and death risks are not uncom- mon (Marshall and Koenig 1996). Further, there has been some concern t\ hat IRBs may require anthropological researchers to engage in behaviors that\ create rather than avoid ethical dilemmas, such as mandating that research part\ icipants sign informed consent forms that result in participants’ names being \ part of a project’s records. In the study of illegal behaviors, such as illicit\ drug use or prostitution, this may contradict the researcher’s commitment to prot\ ect the confidentiality of study participants. Health anthropologists recogniz\ e that the kind of research they conduct commonly encounters perplexing ethical dil\ emmas and recognize the need for ethical principles to guide their research ac\ tivities.

Whether bioethics is the appropriate source for such principles is an is\ sue of debate. Whatever the challenges, as discussed further in chapter 8, ther\ e is little doubt that health anthropology will continue to engage and develop in re\ lation- ship with the field of bioethics (Lambeck et al. 2015).

Health Anthropology Theories As is typical in science generally, health anthropologists understand th\ e world in particular ways. One of the influences on how an anthropologist app\ roaches issues of health or illness is the particular theoretical framework or s\ chool of understanding a health anthropologist uses. There are several such frame\ works in health anthropology, although many individuals do not see themselves as \ adher- ents of any single perspective but rather take a more eclectic approach and allow the problem they are working on to shape the perspectives that they use. Other medical anthropologists consider themselves adherents or even advocates \ of par- ticular points of view. Indisputably, however, the perspective they brin\ g to their research will strongly influence the way a problem is approached, the questions that are asked, and the answers that are deemed sufficient and adequat\ e. Among the primary perspectives found in health anthropology are medical ecolog\ y, the meaning-centered perspective, and critical health anthropology. These ar\ e intro- duced here and given fuller examination in chapter 5.

Medical Ecology Rooted in both cultural ecology and evolutionary theory, this approach b\ egan with an emphasis on adaptation, defined as behavioral or biological changes at either the individual or the group level that support survival in a give\ n environ- ment, as the core concept in the field. From this perspective, health \ was seen as a measure of successful (or poor) environmental adaptation. In othe\ r words, a central premise of medical ecology initially was that a social group’s level of health reflects the nature and quality of the relationships that exist\ at three levels: Introduction to the Anthropology of Health 33 within the group, with other groups, and with the physical environment. Beliefs and behaviors that improve health or protect societal members from disea\ se or injury are adaptive. For example, there is the indigenous development of\ snow goggles that shield the eyes of Arctic dwellers from the damaging glare \ caused by the sun reflecting off ice and snow. This constitutes a small but i\ mportant health-related cultural adaptation of the Inuit people, as do the fur cl\ othing and ice houses of indigenous Arctic dwellers. Similarly, from the medical ec\ ological perspective, behavioral complexes, such as medical systems, including everything from shamanistic healing of soul loss to biomedicine treatment of heart \ disease, can be viewed as adaptive sociocultural strategies for confronting illne\ ss and con- tributing to the ability of a society to survive or even thrive. Similarly, the eco- logical approach is concerned with understanding how, and how well, cult\ ural and social formations address nutritional or other bodily needs. In rece\ nt years, as a result of dialogue with other perspectives, there has been movement\ toward the political ecology of health, indicating a recognition of the multipl\ e ways the environment is shaped by the unequal structure of relations within socie\ ties.

Meaning-Centered Health Anthropology The approach taken in medical ecology to the understanding of human biol\ ogy and behavior, as an interactive set of adaptations to ecological and soc\ ial chal- lenges, makes a lot of sense to many health anthropologists. Yet others \ have questioned aspects of this approach on the basis that from the perspecti\ ve of medical ecology, a disease, as is portrayed in science, is often treated as a natural object. Disease, in other words, is an object separate from human consci\ ousness and human cultural interpretation of the world (B. Good 1994). In turn\ , med- ical systems come to be seen in medical ecology as utilitarian social re\ sponses to intrusive natural conditions. As a result of these premises, in medical \ ecology cul- ture is absorbed into nature, and the work of health anthropology become\ s ana- lyzing the adaptive efficacy of health-related behaviors and beliefs. \ Lost in such understanding is a full appreciation of the human cultural/symbolic cons\ truction of the world we inhabit. Humans can experience the external material wor\ ld only through their cultural frames and thus diseases, as they are known, thro\ ugh body sensations or observations and measurements, by sufferers and healers al\ ike, are perceptions and sensations packed with cultural content. Even medical sc\ ience and biomedicine do not offer culture-free accounts of the physical world\ ; their understandings of disease or of the body also are cultural constructions\ . This is because both of these historically intertwined pragmatic ways of knowing\ the world emerged within particular cultural systems at particular points in\ the devel- opment of those systems, and they accept without thought or questioning \ many deep-seated cultural ideas and values derived from their encompassing cu\ ltural assemblage. For example, deeply embedded within and strongly supported by the day-to-day activities, theories, and organizational structures of bi\ omedicine and medical science are Western cultural notions of (1) individualism,\ namely, that each individual is distinct and is responsible for his or her succe\ ss or failure and self-improvement; (2) progress and the belief that history is a pr\ ocess of 34 Chapter 1 steady social improvement; and (3) the responsibility of action or a b\ elief in the appropriateness of changing the world to meet human needs and ourselves \ to meet cultural goals of maturity, wellness, and social success. Consequen\ tly, from the meaning-centered perspective, a goal of health anthropology is to “\ unpack” and analyze everything that makes up the health arena, from the experien\ ce of pain to the training and functioning of healers, as a set of systems for\ creating, experiencing, and communicating meaning in human life. Some researchers have emphasized that a meaning-centered approach, in addition to its analytic utility, has practical value in addressing heal\ th issues.

For example, a meaning-centered approach may have value in children’s\ can- cer treatment because it promotes the development of a way for caregiver\ s to understand and respond to children’s immediate experience of symptom distress, including the meanings and culturally influenced feelings children att\ ach to par- ticular symptoms throughout their illness trajectory (McClement 1998).\ Critical Health Anthropology During the early years of health anthropology’s formation, explanatio\ ns within the discipline tended to be narrowly focused on explaining health-relate\ d beliefs and behaviors at the local level in terms of specific ecologic\ al conditions, cultural configurations, or psychological factors. While providing ins\ ight about the nature and function of diverse medical models, the initial perspecti\ ves in the field tended to ignore the wider causes and determinants of human \ deci- sion making and behavior. Explanations that are limited to accounting fo\ r health-related issues in terms of the influence of human personalities\ , culturally constituted motivations and understandings, or even local ecological rel\ ation- ships, some health anthropologists began to argue, are inadequate becaus\ e they tend not to include examination of the structures of social relatio\ nship that unite (in some, often unequal fashion) and influence far-flun\ g individuals, communities, and even nations. A critical understanding, by contrast, in\ volves paying close attention to what has been called the “vertical links”\ that connect the social group of interest to the larger regional, national, and globa\ l human society and to the configuration of social relationships that contribute to the patterning of human behavior, belief, attitude, and emotion (Singer and\ Baer 1995). Consequently, what came to be called critical health anthropolog\ y (CHA) focused attention on understanding the origins of dominant cultu\ ral constructions in health, including which social class, gender, or ethnic\ group’s interests particular health concepts express and under what set of histo\ ric con- ditions they arise. Further, CHA emphasizes structures of power and ineq\ uality in health-care systems and the contributions of health ideas and practices to reinforcing inequalities in the wider society. Moreover, CHA focuses on \ the social origins of illness, such as the ways in which poverty, unhealthy living and working conditions, discrimination, stigmatization, violence, and fe\ ar of violence contribute to poor health, as well as the political-economic an\ d polit- ical-ecological sources of these causes of unequal health. The four auth\ ors of this book have been active throughout our respective careers in contribu\ ting to the critical health anthropology perspective. Introduction to the Anthropology of Health 35 From an applied perspective, critical health anthropologists seek to con\ - tribute to address questions such as: How are we to understand the natur\ e of industries and governance structures that facilitate disease by pollutin\ g (or allow- ing the polluting of) the environment and furthering global warming (w\ hich constitutes a severe and multidimensional threat to human health) or ot\ her ecocrises? What drives an economic system that makes possible the manufa\ cture and release of “killer commodities”—consumer products, such as \ those routinely advertised on children’s television that are high in fat, sugar, or s\ alt, that cause injury, illness, or death—onto the global market? What forces have pu\ shed, and what kinds of social relationships support, the biocommodification of \ nature, including the production of genetically engineered food crops and invasi\ ve and exploitive biotechnologies, like the global systems that lead to the mov\ ement of transplantable organs and tissues from poorer countries to richer countr\ ies and poorer donors to richer recipients? Contrary to what some have asserted, CHA does not take a “top-down approach” that denies people’s ability to resist and fight back \ against oppressive relationships that harm their health. Rather, critical health anthropolo\ gists argue that lived experience and “agency,” including individual and group decision making and action, are “constructed and reconstructed in the action arena be\ tween socially constituted categories of meaning and the political-economic forces that shape the context [and texture] of daily life” (Baer et  al. 2003:44). In other words, people develop their own individual and collective understandings and responses\ to illness and to other threats to their well-being, but they do so in a world that\ is not of their own making, a world in which inequality of access to health care, \ the media, productive resources (e.g., land, water), and valued social statuses p\ lay a significant role in their daily options. At the same time, critical health anthropol\ ogists do not explain all experiences of body/self disorder as an expression of social\ critique or resistance. Often, in fact, illness experience and the way it is handled\ socially serves only to reinforce rather than throw open to question existing structures\ of power. Additionally, while recognizing the fundamental importance of physical (including biological) reality in health, such as the nature of particular pathogens, CHA emphasizes the fact that it is not merely the idea of “nature”\ —the way external reality is conceived and related to by humans—but also the v\ ery physical shape of nature, including human biology, that has been deeply influen\ ced by an evolutionary history of social inequality, overt and covert social co\ nflict, and the operation of both physical power and the power to shape dominant ide\ as and conceptions in society and internationally through processes of glob\ alization (Whiteford and Manderson 2000). In the following chapters, we return to many of these ideas while emphas\ iz- ing the ways in which health anthropology—guided by any of the perspe\ ctives described here—actively seeks to understand health, health beliefs an\ d behav- iors, and healing systems and practices across time and place and to use\ this information in addressing health problems, conflicts, and suffering in\ the world.

We begin this process in the next chapter by examining what health anthr\ opolo- gists do, including the ways they approach problems, the kinds of proble\ ms they address, their collaboration with other health-interested disciplines, a\ nd their impact on the health arena. 36 Chapter 1 Discussion Questions 1. A core question of this chapter is “why have a health anthropol- ogy?” What do you think?

2. Why is health far more than a biological or medical issue; what other factors need to be considered to understand both how and why people get sick and how and why they get better (or fail to do so)?

3. Why do health anthropologists tend not to accept any particu- lar health-care system, including Western biomedicine, as holding a monopoly on useful health knowl- edge or effective treatment? Is this position justified?

4. What are some of the ways anthro- pologists have responded to den- gue? With Zika and other spreading mosquito-borne diseases, what factors might contribute to a major mosquito-related U.S. epidemic?

5. Why are social relationships, such as those between ethnic groups, and social structures that deter - mine access to resources and other things of value fundamental to health and disease?

6. Besides those mentioned in this chapter, can you think of any other cultural metaphors that ex- press how we think and talk about health and disease?

7. How do anthropologists engage the issue of ethics? Why are ethics important in health anthropology?

8. What are the key distinguishing features of critical health anthro- pology? What do you think about this orientation? 37 2 The distinctive approach of anthropology to research is to go out and se\ e what is actually occurring, and to talk to the people themselves. —John Janzen (2001:18) Introduction and Overview I n the previous chapter, a point we stressed is that health anthropologis\ ts are involved in a wide variety of health-related issues, places, and kinds o\ f work.

This chapter provides a closer examination of just what it is that health anthro - pologists actually “do” in these various settings. We begin by pro\ viding three additional cases of health anthropologists at work, including an explora\ tion of the kinds of problems they address and how they go about applying health\ an- thropology. Based on these cases, we then (1) discuss the range of issues health anthropologists study and the special focus they bring to their work bec\ ause they are anthropologists; (2) describe the distinctive health anthropology approach to research within the broad, holistic vision of our field; (3) examine the methods used in health anthropology research; and (4) explore applied activiti\ es in health anthropology beyond research.      Three Settings, Three Case Studies, Three Health Anthropologists Life and Death in Tanala Studying Indigenous Healing Sitting on the doorstep of Ranomafana National Park in the southern part of the island nation of Madagascar is the small Tanala village of Ranotsara (pseud- onym). Located in the Indian Ocean off the southeastern shore of Africa, to the east of Mozambique, Madagascar is well known for its shimmering forests and seething mass of biologically unique and richly diverse plant and animal\ species, such as ancient and exotic baobab trees, exceedingly slow-moving chameleons with strangely rotating eyes, and loud packs of lemurs, including the very rare Golden Bamboo lemur. Sadly, the Republic of Madagascar also is known as a land of aggressive deforestation. Ranomafana National Park, in fact, was estab- lished in 1990 with private and public funding from the United States as well as from international entities such as the World Bank. It is administered primarily What Health Anthropologists Do 2 CHAPTER 2 WHAT HEALTH ANTHROPOLOGISTS DO 38 Chapter 2 by U.S. citizens with the express goal of preserving biological diversity and eco- systems by linking conservation with improved standards of living for the people who dwell in and near parklands.

When health anthropologist Janice Harper arrived in the village to begin her research in April 1995, about 180 people, about a third of them children and teens, were living there, divided among thirty thatch-and-tin-roofed homes, most of which were rusted and leaking. Surrounded by irrigated rice fields, the village constituted a manmade island nested on hard-packed reddish dirt. Harper had come to study the indigenous use of medicinal plants and nontraditional medi- cines, customary topics of health anthropology research, but right from the start events on the ground began to challenge and reshape her research plans.

The Cultural Construction of Hygiene Harper initiated her research project with door-to-door introductions with all the villagers, followed by a set of “invasive but excessively polite demographic questions” (Harper 2002:166). Subsequently, she interviewed people about their health problems, understandings of health issues, and acquisition and use of forest and Western medicines, among other topics. She observed and par - ticipated in daily village activities and filled her notebooks with deta\ iled accounts of what she saw and heard. As she lived among the villagers, witnessing their routines in the fields and around the village, and casually interviewed them about their use of healing plants and other mundane issues of day-to-day\ vil- lage life, Harper realized that the villagers’ conceptions of health and cleanli- ness were different from her own, Western, middle-class ideas. Attempting to be ecologically sound, she tried to bury all her garbage, from crumpled papers (reflecting false starts in her writing efforts) to the tin cans and plastic bags from the used-up Western products she had carried with her to the field. The villagers, who produced little if any garbage, were astonished by the amount she produced—which, very likely, was far less per day than the average mid- dle-class home in the United States—and they believed her to be very rich to be able to make so much garbage. Indeed, many of the things she discarded, such as used-up glass bottles, they coveted as useful containers. Everyt\ hing else that she buried the pigs rooted up and scattered about. Washing was another issue. In a place where a bar of soap costs a full day’s wage, water doesn’t run from a tap, and the latrine consists of the spaces between the trees in the nearby coffee grove, keeping clean is a constant challenge that is com- plicated by the fact that daily labor—from sunrise to sunset—in the rice fields means standing in calf-deep mud that is thick with worms and feces, whil\ e work on the nearby hillside gardens involves toil in the blazing sun. Most peo- ple’s clothes were tattered and their bodies scrawny but strong from daily man- ual labor. As for the children, Harper found that almost all had bloated bellies as a result of worm infestation, their skin was encrusted with lesions caused by scabies (a microscopic burrowing insect), their legs and arms were marked by large boils, their ears were leaking yellow pus from infections, and their bodies What Health Anthropologists Do 39 were mostly underweight, and yet they were active and playful and filled the village with their laughter.

In the Company of Death Harper also was struck by the frequency of sickness and death around her.

Indeed, a woman who sought employment from Harper on the anthropologist’s first night in the village had died by the following morning. During her fourteen months in the village, eighteen people died, a disturbingly high mortali\ ty rate of almost 100 per 1,000 population compared with just more than eight deaths per 1,000 population in the United States.

Her fieldwork ultimately ended as it began with the death of a villager. On the morning of her departure—under pressure from park officials not to express any criticism of the park or to imply that the park was a factor in vill\ age morbidity and mortality rates—Harper (2002:235) was awakened “not to the e\ erie cries of the lemurs,” which had enchanted her mornings and nights in Ranotsara, but to “the ghostly cries of women wailing for the dead. Maily, a young woman in her twenties, had died during the night.” Writing Up On her return to the United States, Harper wrote a book titled Endangered Species: Health, Illness, and Death among Madagascar’s People of the Forest to document her findings and to show that while the people she studied use plants, barks, and roots from the forest to treat (but rarely cure) debilitating diseases that are readily cured with pharmaceutical medicines, the latter are usually inaccessi- ble. Harper (2002:3) argued that “their continued reliance on the forest’s botany for their health care is less conditioned by their ‘culture’ than it is by social inequalities that have rendered them cash poor.” Even the forest at their doorstep is controlled by others, turning their social disparities into health disparities, an issue of keen interest to health anthropologists that is examined in chapter 4. Rather than exist- ing in an exotic village with a traditional way of life sheltered by dense forest from the fast-paced and changing world system around them, the lives of the peo- ple of Ranotsara, Harper found, are shaped, although not narrowly so, by forces beyond their reach and certainly beyond their control. Harper seeks to reveal what can happen in contemporary development, including the ecological develop\ ment movement, when people are not treated as part of the natural environment that is being protected, issues that are addressed more fully in chapter 5. To make her points, Harper relies not solely on her own research findings but also on an exam- ination of historic records, economic reports, and population data.

Studying Surgeons Problems at Meadowbrook Many miles from Ranotsara and seemingly a world away from its humid green landscape lies Meadowbrook University Hospital (pseudonym) on the outskirts 40 Chapter 2 of one of Canada’s largest cities. With 800 patient beds, 120 of which are reserved for surgical patients, Meadowbrook doctors perform 15,000 opera- tions each year. As a university hospital, in addition to providing health care to patients, Meadowbrook is a teaching institute and thus is home to a steady and changing flow of medical and other students seeking to become health-car\ e professionals, and, further, it is a health-care research center oriented to increas- ing the fund of biomedical knowledge.

Despite its sanitized veneer of orderliness and control, Meadowbrook had a problem. The hospital began to receive urgent complaints from surgical residents in their final stage of training that the staff surgeons who were their teachers and supervisors were not spending enough time training them to be surgeons. In response, as noted in chapter 1, Pearl Katz, a health anthropologist, was invited by the chief of the Department of Surgery to carry out a study that woul\ d help resolve the problem. Katz realized that the study held the potential to be of even greater importance than the immediate needs of the Department of Surgery.

Health anthropology, which views biomedicine as ethnomedicine—if of a special sort, namely, a medical system that has gained global importance and a domi- nant position in terms of other ethnomedical systems internationally—is keenly interested in understanding how biomedicine works, including its roles in soci- ety, its worldviews and underlying cultural models, social structures, and variet- ies across time and place.

Expect Rejection When Katz (1999:16) began her study, she was “warned by friends and col - leagues that [she] would have difficulty getting accurate information on what surgeons did.” Katz’s anthropological colleagues assumed that the surgeons, being privileged and, relative to patients and researchers at least, rather pow- erful, would limit her access to information, especially to unfettered backstage glimpses of their lives and behaviors. Certainly other researchers have had trou- ble gaining full access to biomedical practitioners. In her own study of\ surgeons, for example, health anthropologist Joan Cassell—a colleague who encouraged Katz to publish her findings—was once sternly asked by a surgeon after an operation to which a nurse had invited her to observe, “What’s an anthropologist doing studying surgeons?”—to which she glibly responded, “Well, there were no other primitives left” (Cassell 1998:10). Cassell’s experience notwithstanding, Katz found that the surgeons extended her an extraordinary level of trust and openness; they appeared to her to want to be understood.

Instead, Katz found herself challenged by her own attitudes toward sur - geons. It was much easier for her to identify with patients and she was \ criti- cal of the disparaging attitude surgeons expressed about the concerns of their patients. She was shocked to find that they referred to an especially frightened patient as the “beast” or the “colon.” Only over time, after\ observing many oper - ations, did Katz realize that she too was depersonalizing patients and why this What Health Anthropologists Do 41 was a useful mechanism that enabled surgeons to “protect themselves against the [emotionally burdensome] experience of empathizing with the personal anguish of patients” (Katz 1999:8). Katz also found herself envying\ the power held by surgeons and came to realize that to some degree such envy fuels dia- tribes against the status of surgeons found both in the popular mass med\ ia and in some social science analyses.

Following Doctors In her day-to-day work on the study, Katz focused intensely on six senior sur - geons. With each of these key informants she spent approximately three con- tinuous weeks, from the moment they arrived in the hospital early each morning until they left the hospital about twelve hours later, a method known as “shadow- ing.” As one of the doctors she studied noted in introducing her to a colleague, “Look, I’ve got a girl following me around all the time, taking down everything I say” (Katz 1999:7).

Over time, Katz (1999:91) developed a number of keen insights about “\ sur - geon culture,” including the fact that while they act jovial and gregarious in the company of their colleagues, surgeons tend to carefully protect “information about themselves, their patients, their operating loads, operative techn\ iques, referral sources, levels of specific knowledge, specific expertise (particularly deficits in knowledge and expertise), income, and doubts and concerns about medical decisions,” in other words, anything that might allow another surgeon to have the upper hand in dealings with them. Feelings of competition with other surgeons, in short, were as strong as or stronger than any sense of collegiality and collaboration. This underlying feature of surgeon culture, Katz found, was a critical component of why residents felt that hospital staff surgeons were not spending adequate time training them for their jobs as surgeons.

Folk Illness in Haiti Illness and Identity Far to the south of Meadowbrook University Hospital, on the Caribbean island of Haiti, lies the rural village of Jeanty (pseudonym), tucked into the foothills above the Cayes plain, once one of the wealthiest sugar-growing areas of the world. The village itself is hilly and rocky and was probably first populated during the early nineteenth century by freed slaves fleeing plantation labor in the early years of Haitian independence from colonial France. Little more than a cluster of small tin-roofed houses strewn along a grid of unpaved streets, Jeanty is home to three thousand people with a total population of almost twelve thou- sand in nearby hamlets. With American funding, CARE, a relief agency (one of many in Haiti), had installed a potable water system in the village, an\ d it was with the assistance of CARE that Paul Brodwin, a health anthropologist, had arrived there in 1987 to study folk conceptions of illness, healing, and mortality. 42 Chapter 2 Specifically, Brodwin examined the crisis of illness as a fundamental social expe- rience during which people commonly rework their social identities and confront the contradictions of their life experience, health-related processes addressed in chapter 3.

The Language of Research Brodwin’s research methods included participant observation of routine health-related activities among village members, semistructured interviews with village residents, attendance at community religious and healing rituals, the col- lection of life histories of village members, and interviews designed to\ record detailed narratives of actual illness experiences. He was aided in this effort by being a novelty for the villagers: only a handful of outsiders have ever lived in the village, and thus locals were interested in talking with him. Initially, Brodwin had an assistant, a young man from the village, but before long his ability to speak Creole—the language born of the merger of French and several languages from West Africa—was sufficient to conduct his own interviews.

Choosing a Healer In his study, Brodwin addressed an issue that is central to health anthropology (see chapter 7): in contexts of medical pluralism (i.e., coexistent a\ lternative heal- ing systems), how do people make decisions about which ethnomedical sys\ - tem to go to—for what health issues and why—and what actually happ\ ens as patients and healers interact? When they get sick, people often must choose between multiple and competing healing traditions. This is the case both in the small-scale communities where anthropologists commonly have worked and in the urban centers where many anthropologists now do their research. To help answer these questions, Brodwin observed more than fifty consultations between patients and herbalist healers and about twenty interactions bet\ ween patients and houngans (male healers in the Vodou folk health-care system). In each case, he carefully recorded his observations of what happened, including the nature of the problem brought by the patient, healer questions and actions, patient responses, the context and tone of the interaction, and the issue of pay- ment. For example, about one consultation by a Haitian patient suffering from painful muscle aches and body fatigue, Brodwin (1996:134), who accompanied the patient, named Louis, to the healing session, recorded, André [a houngan known to the patient] greeted us at the door, and after the necessary introductions, led us into his small consulting room and sat at his table. It was covered with a heavy red cloth, and an assortment of small bottles filled with remedies lined the back. . . . As André settled in his chair, he lit an oil- wick lamp. . . . [After a while] André began to moan and gasp for air between coughs which wracked his entire upper body. . . . He soon began to rock back and forth and softly whistled, a serene smile on his lips. . . . From this moment on until the end of the consultation . . . we communicated only with his lwa [the spirit being named Byenzomal that had possessed André and began to speak What Health Anthropologists Do 43 through him]. . . . When he had finished the divinations [to deter\ mine the source of Louis’s symptoms] and given to Louis the names of several [folk] remedies to purchase, Byenzomal rang the bell . . . and announced “We’re through.” Studying Exotica To his fieldwork project, Brodwin brought a strong curiosity about the exotic, one that was not disappointed by scenes such as the one just described. \ As Brodwin (1996:129) admits, “Years of graduate training in anthropology had not suppressed my typically American fascination with the exotic side of popular Haitian religion.” To his initial disappointment, however, he was frustrated in this desire at every turn. Several months passed before he was finally able to make contact with and begin interviewing a houngan.

In his interviews with village members, Brodwin came to realize that while people may consult houngans for their pressing health problems, it is not with- out a degree of fear of the malign ability of these specialists to “send sickness.” Fear—although of a different sort—plays a similar role in the hesitancy many people in the United States feel about seeing a dentist or having an ope\ ration.

As Brodwin learned, ambivalence, uncertainty, and moral struggle are often crit- ical features of illness and healing, lessons learned by health anthropologists working in diverse social and cultural settings.      A Case Study Having Impact As Erickson (2003:3), whose work in health anthropology addresses repr\ oduc- tive health issues, points out, Medical anthropology has a broad mandate—to understand and interpret hu - mans, their diseases and illnesses, and their medical systems. Many medical an- thropologists also take on the responsibility of making their research useful for clinical or health educational applications, for influencing public health policy, or for effecting social justice.

Through this brief examination of the fieldwork of three different health anthropologists in different parts of the world and with very different \ field sites and populations, as well as different research questions and methods (i\ ncluding, in addition, the three examples provided in chapter 1), we begin to grasp \ just what it is that health anthropologists do to fulfill the discipline’s br\ oad humanitarian and scientific mandate. Some of what they do, indicated by the six cas\ e studies presented thus far includes (1) at times, focusing their research and \ applied efforts directly on specific diseases (e.g., cystic fibrosis or dengue), and in other cases, concentrating on particular healing traditions (or multiple traditions \ in inter- action), to reveal underlying factors missed by less intensive, less field-oriented 44 Chapter 2 approaches to research; (2) addressing gaps in health-care services th\ at often only are revealed by up-close, ethnographic research; (3) seeking to understand the provider-patient relationship and the nature of the healing process; (4\ ) investi- gating local health beliefs, practices, and concerns to help shape publi\ c health efforts to match their target audiences and promote community involvement; (5) working “on the ground” among people as they live their everyday lives in order to spot and develop understandings of risk behaviors (and their causes) as well as risk contexts that promote unhealthy behaviors and exposures; (6) t\ rying to understand the social origins of illness and use this information to mak\ e specific policy change recommendations to reduce health risk; (7) determining the contri- bution of social inequality and injustice to inequities in health outcom\ es; and (8) exploring biosocial and socioenvironmental interactions to better compre\ hend the making of wellness and disease relative to other species, environmental \ features, and the climate. Ultimately what health anthropologists do is seek to im\ prove health, generally with groups that face the biggest health challenges an\ d threats.

What Health Anthropologists Study A Diverse Discipline In the role of applied social scientists, health anthropologists commonl\ y seek to answer practical questions about the nature of health, illness, healing \ systems, and related matters across cultural systems, populations, and social contexts.

These questions derive from various sources. Some reflect ongoing deba\ tes and discussions generated at anthropology (and other health) conferences a\ nd in the published literature, primarily books and journals but also government o\ r other reports, policy papers, and other documents of the discipline and relate\ d fields.

Others are raised by institutions, government bodies, or communities tha\ t seek the help of a health anthropologist in addressing pressing issues. Still\ other ques- tions arise because of changes in the world that impact health. For exam\ ple, the rapid increase in electronic communication (especially cell phones and \ computers) has influenced health-related behavior in various ways (e.g., the rap\ id electronic accessing of health information on the internet). Increasingly, health \ anthropolo- gists, like other researchers, have asked research questions about the i\ ntersection of health behavior and electronic communication including social media. \ During the 2014–2016 Ebola epidemic, for example, Olivia Marcus and Merrill \ Singer (2016) analyzed the appearance of an internet meme known as Ebola-chan\ that began to show up on various internet sites. This unexpected anime character— an anthropomorphic internet representation of the Ebola virus—combined the appearance of girlish innocence and an inversion of the meaning of carin\ g (in the sense of loving someone to death) with morbid imagery to encapsulat\ e con- flicted social responses to a lethal and fast-spreading epidemic in th\ e digital age.

Drawn and posted anonymously, the meme appeared on various internet site\ s, garnered a range of posted reactions, triggered the creation of various other infectious disease memes, then faded away as the epidemic peaked and beg\ an to recede in the global social imagery. A similar internet response does no\ t seem to have accompanied the 2015–2016 Zika epidemic despite the widesprea\ d fear What Health Anthropologists Do 45 generated by the linkage of this mosquito-transmitted disease with micro\ cephaly and fetal malformation. As these examples suggest, the internet is a dom\ ain of health-related behaviors and communication in critical need for enhanced health anthropology research and understanding. Also of concern to health anthropologists is the role of governance in t\ he framing of global health issues. Governance refers to how a governing bo\ dy or other institution with sway in society views its mission and carries it \ out through policies and actions. Part of governance is what Michel Foucault (2008)\ called governmentality or the way governments and other social control institutions try to shape their citizens to be particular kinds of people or, in the \ case of the governmentality of hospitals and clinics, particular kinds of patients. \ The U.S.

government, for example, stresses the making of responsibilized citizens\ who see issues like illness, health insurance, unemployment, and poverty as \ not being the responsibility of the state or society, but instead as the private b\ urden of individuals and families. Consequently, there is a strong and often mora\ listic emphasis in American culture on self-care, often actualized as care through con- sumption (buying particular foods, joining gyms, taking yoga classes, purchasing the right gear for all manner of sports). In research on emergent popul\ arized views on cancer, for example, adopting a healthy lifestyle is being defined as a way of preventing disease, based on the understanding that the epidemiol\ ogical literature firmly demonstrates the role of factors such as weight, die\ t, and exercise on cancer risk. But, in fact, “scientific findings on the cancer/\ lifestyle link” show that they “are incomplete, ambiguous, and internally contradictory”\ (Bell and Ristovski-Slijepcevic 2015:219). At the global level, health anthropolo\ gists are examining global health governance and the ways global health issues are\ framed.

This concern stems from recognition that how health problems are conceiv\ ed will shape global efforts to respond to them. Without doubt, health anthropologists have diverse points of view and do\ not by any means fully agree about what the key questions of the discipline are. Some health anthropologists, those interested in the experience of \ illness, focus much of their attention on humankind’s phenomenological encounter with being sick, asking questions such as what does illness mean to peop\ le in particular social roles, sociocultural contexts, and social settings? Wh\ at is the internal lived experience of illness like for sufferers and what shapes \ this expe- rience? What impact does illness have on their identities, relationships\ , and values? Concern about answering such questions has led some anthropologi\ sts working on health issues to adopt the concept of subjectivity. Subjectiv\ ity refers to the internal thoughts, feelings, and worries of people as well as the\ ir intent, desires, and images of self—in short, the emotion-laden fabric of the\ ir inner lives in social context. Subjectivity, from the anthropological perspective, i\ s not an individual or private state, but rather involves how people in common si\ tuations, facing common challenges, develop overlapping and meaningful ways of bei\ ng, knowing, and experiencing in the world (Good 2012). Central to the not\ ion of subjectivity is examination of behavior, including health-related behavi\ or, as a dynamic and fluid process, an emergence, rather than one narrowly cons\ trained by cultural conventions (Abadía-Barrero 2011). This means a study o\ f behavior as conscious action relative to others and inner lives as products of in\ teraction 46 Chapter 2 and intersubjectivity. A study of gender and mental health treatment in \ different clinical and home settings in northern India (Pinto 2014), for example, focused on how women experience the vulnerabilities of love in their minds, thro\ ugh their bodies, and as part of their social world of interactions. In both\ the Hindi and Urdu languages, in fact, love and madness are both considered forms \ of nasha or intoxication. Loving the wrong person in an intense, driven way, cra\ zy love, is constructed culturally as a destructive force that shattered th\ e wellness of not only the women patients Pinto studied but their families as well.\ During her fieldwork, Pinto herself faced a jarring personal crisis, which sh\ e writes about as an intersubjective aspect of her research experience, a broken mirror\ that reflected the broken inner worlds of the women about whose lives her w\ ork poignantly examines. Other health anthropologists are more interested in how people make deci\ - sions about what to do when they are ill, including their help-seeking s\ trategies, how they select among alternative healing systems or combine different t\ ypes of treatment, and the role of significant others in shaping these process\ es. Alterna- tively, there is keen interest in both the nature of the patient-healer \ relationship and the relative effectiveness of different approaches to treatment amon\ g various health anthropologists. Finally, some health anthropologists are especia\ lly con- cerned with the role of environmental, social, political, and economic factors in illness. In this book, we engage all of these issues of concern to the fi\ eld by way of introducing the range found within the discipline. Further, health has a global research mandate. As seen in the examples that have been provided, some health anthropologists work in rural villa\ ges in developing nations, others conduct their studies and applied work in mod\ ern hospitals, while others carry out their research on the street corners o\ f cities large and small, or even on the internet. Many health anthropologists wo\ rk in quite different settings over the course of their careers. A complete co\ mpilation of all the topics health anthropologists have addressed and all the plac\ es they have conducted research or implemented programs would be surprisingly long and varied. The discipline requires that its practitioners have a good s\ ense of our changing world and the dynamic domain of health in human societies, and \ even beyond humans to interacting species that may be the source of zoonotic \ human diseases or cures.

Studying the Life Course Another reflection of the broad mandate of health anthropology is the \ work done by members of the discipline across the various stages of the human\ life course, from birth (or even before, in terms of reproductive health) t\ o death.

In all societies, reproduction and reproductive health are heavily inves\ ted with cultural meanings and values. Women’s menstruation, likewise, is comm\ only a focus of cultural elaboration; menstrual blood often is seen as being especially charged and possibly polluting. The process of giving birth also is cult\ urally shaped and managed in all societies according to group understandings of\ appropriate birthing behavior. With her classic anthropological study Birth in Four Cultures, Brigette Jordan (1993) helped launch the anthropology of birth What Health Anthropologists Do 47 and reproduction as a subfield of health anthropology. Work in this ar\ ea has shown that cultures develop distinct beliefs, meanings, and associated p\ ractices around pregnancy, delivery, and the treatment of babies during the postp\ artum period. Further, researchers working on this topic have demonstrated tha\ t there is a need for an examination of birthing within structures of power in h\ ealth care and in society generally, and in light of both women’s culturall\ y influenced priorities and factors such as their attitudes toward pain, fear, stress\ , and anxiety.

In biomedicine, for example, the full medicalization of childbirth—ch\ aracterized by (1) the use of high-tech machinery for monitoring the birthing proc\ ess that begins early in the pregnancy and continues through delivery, (2) freq\ uent use of surgery to both widen the birth portal and remove the baby, and (3) wi\ despread use of medications to deaden pain or speed up the birthing process—ha\ s led to the use of the term “technocratic birth” to characterize having a baby in Western society (Davis-Floyd 1992). An informative study of the role of social\ class and educational influences on women’s birthing behaviors in Chile focus\ ed on the period before delivery (Murray 2012). Rather than there being a single Chilean pattern of birthing preparation, there were different patterns structure\ d by social class and access to differential material resources. However, as the tim\ e of birth approached and women’s sense of vulnerability and risk increased, the\ class strat- ification in attitudes about the medicalization of birth collapsed int\ o a general, cross-class acceptance of the choices made for women by the biomedical s\ ystem.

Fear and uncertainty came to override prior choice and led to acquiescen\ ce to socially enforced biomedical authority. By contrast, in many societies, \ traditional birth attendants (i.e., senior women with considerable personal and app\ rentice experience in birthing) provide the primary support to a woman in deliv\ ery.

Low-technology, midwife-assisted birthing systems have resisted the spre\ ad of technocratic birth, often with anthropological support. An applied approach to the issue of birthing has led to anthropological work on issues such \ as teen pregnancy as a health and social problem, including showing why teen gir\ ls often view pregnancy as a sought-after social status (Erickson 1998). Simila\ rly, health anthropologists have studied children’s health and have been active i\ n applied projects such as breastfeeding promotion. Some anthropologists, for exam\ ple, became very involved in the effort to challenge the global promotion of \ commer- cial infant formula by Nestlé Corporation and other companies as a re\ placement for breast milk (e.g., Penny Van Esterik 1989). In many settings, manufactured formulas, they have argued, are detrimental to children’s health and \ sometimes, if clean water for mixing the formula is not available, even life threateni\ ng. Breast- feeding, by contrast, not only provides a nutritious food for babies; it\ also passes important maternal immunities to diseases on to young children. Chapter \ 8 considers the human dimensions of the emergence of biotechnology, the ro\ le of biocapital and the emergence of markets for body tissues, and the growin\ g array of bioethical issues in which health anthropologists are now engaged. At the distal end of the life course, since the 1950s anthropologists ha\ ve also paid considerable and increasing attention to aging. Research in this ar\ ea has shown that old age commonly is marked by a shift in a person’s role i\ n society, such as a significant reduction in work responsibility, as well as cha\ nges in social status, including, depending on the local setting, coming to be viewed v\ ariously 48 Chapter 2 as a valued storehouse of important cultural knowledge or as out of touc\ h with the contemporary world. The nature of these transitions varies because t\ he meanings attached to being “old” are culturally constructed in lig\ ht of other fea- tures of a society. In a fast-paced, rapidly changing, and globalizing s\ ociety, the knowledge and experiences of elders may be devalued; by contrast, in soc\ ieties that look to tradition as a guide to the present, growing old may be acc\ ompanied by a gain in social stature. Increasingly, however, as the global market\ (e.g., labor migration) has had its impact, there have been significant but locall\ y varying changes in intergenerational relationships. In China, for example, where\ the elder population has been growing rapidly and becoming a higher percentage of \ the total population, traditional values of elder respect, family support, a\ nd obliga- tion to caregiving face new challenges and moral dilemmas (Sheng and Se\ ttles 2006). Broad economic and social changes have weakened the social found\ ations of family care for elderly parents and elderly expectations about being \ cared for later in life by their grown children. Parent-child relationships in Chi\ na have become less hierarchical in recent decades, and, as contrasted with the \ past, elder parents exert shrinking influence on their grown children’s life de\ cisions. Elder parents, in fact, are contributing to their grown children’s independ\ ence through their growing role in taking care of their grandchildren. While family s\ upport and caring certainly have not disappeared, remain expressed values among par\ ents and children alike, and include both emotional and financial support, \ increasingly the government has played a role in elder care through the provision of \ nursing homes, day centers, and elder entertainment centers. Another topic of concern in the anthropology of aging is medicalization.\ For example, since the introduction of Viagra (also see chapter 7 for d\ iscussion of this drug), there has been a biomedically driven redefinition of decr\ eased erectile function accompanying aging vis-à-vis the disease diagnosis known as \ erectile dysfunction. The medicalization of older people’s sexual health bring\ s together Western social discomfort in response to aging with the valorization of \ penetra- tive sexual practice as “normal sex.” In this context, drugs like \ Viagra provide biomedicine with the possibility of improving health, defined in this \ culturally influenced context as youthful sexuality. Such drugs are an enormous s\ ource of profit for the pharmaceutical industry (e.g., Viagra produced almost \ $8 billion in revenue between 2012 and 2016 [Statista 2017]). Moreover, they are m\ ar- keted globally and represent the spread of Western cultural views of agi\ ng and the body, which reduce the aging process and the lived experience of the\ elderly to a form of fixable mechanical breakdown. However, not all men buy in\ to this redefinition. Health anthropology research based in the urology depart\ ment in a government hospital in Cuernavaca, Mexico (Wentzell 2013), for examp\ le, found that male patients understood their decreasing erections as both n\ atural and a physical sign that it was time for them to move past a youthful fo\ cus on penetrative sex and live a more “mature” masculinity based on emot\ ional interac- tions with their families. This decision, encouraged by their wives, enabled these men to embrace local cultural values pertaining to respectable older man\ hood.

Such research demonstrates the continued impact of local cultural values\ on gen- dered life-course behaviors in a globalized world. It also represents th\ e growing What Health Anthropologists Do 49 concern that a consciously gendered focus on health not be limited, as i\ t often has been in health anthropology, to women’s health issues. Applied work in the anthropology of aging has focused on many issues, in\ clud- ing helping to give voice to elders whose needs and capacities have been\ overlooked in society. Applied health anthropologists have developed ties with an i\ nternational movement working to promote elder-friendly communities and the promotion of well-being throughout the life course. Dying and death are also issues o\ f concern in health anthropology; they constitute profound arenas of human experie\ nce, thought, and emotion. In contemporary health anthropology studies, dying\ and death are viewed as “subjects without clear boundaries, and any analy\ tic explora- tion of those themes now problematizes their definition” (Kaufman \ 2004:245) rather than viewing them as clear-cut biological states. In other words,\ death and dying must be understood in sociocultural context because what it means to die in one society may be quite different from what it means to die in another.\ Conducting Research: A Peculiarly Anthropological Approach Holistic, Field-Based Understanding In conducting research, health anthropologists tend to assume that the i\ ssues of immediate concern to them are embedded in wider sociocultural systems an\ d are intricately interconnected with many other aspects of social life and wi\ th com- plex social environmental contexts. As a result, they tend to cast a wid\ e research net and ask a broad set of research questions. To carry out their research, health anthropologists usually marshal a number of qualitative and quantitative\ methods for the collection of health-related data (e.g., see the seven-volume set Ethnog- rapher’s Toolkit, which fully describes the methods used by many health anthro- pologists in their research [Schensul and LeCompte 2010]). Moreover, he\ alth anthropologists generally seek to move out of the university or other in\ stitutional setting in which they are employed to gain direct and intimate access to\ the daily lives and activities of the people under study. Further, they often spen\ d long periods of time in these field settings observing and participating in the flow of life. This is an approach to research known as ethnography.

Ethnography Ethnography is the name of the core research strategy in health anthropo\ logy.

It involves the immersion of the researcher or team of researchers into \ the social space and lifeways of the people under study. As part of this eff\ ort, health anthropologists seek to participate (to varying degrees) in the normal\ social life of the group under study. While not all research in health anthropo\ logy is ethnographic, there is a generally shared sense that ethnography offe\ rs keen insights about health and behavior that are not easily acquired through \ other means. Rather than a highly controlled and sharply focused approach to d\ ata collection, ethnography focuses on issues of concern within their natura\ l social context and in terms of how they are seen and experienced by group membe\ rs. 50 Chapter 2 Choosing Risky Behavior In studying health issues, health anthropol- ogists often use ethnography to address difficult questions or seek to make sense of puzzling or misunderstood behaviors.

Elisa Sobo, for example, was confronted with the challenge of understanding why people who know about AIDS and routes of infection nonetheless regularly participate in risky behaviors, such as not using condoms during sex. This is an important problem for public health because it is clear that simply teaching people about AIDS as an infectious dis- ease does not eliminate risk; the disease continues to spread. In the United States, ethnic minorities have been disproportion- ately affected by AIDS since cases were first identified, and constitute the major - ity of new diagnoses in the ongoing epi - demic (Kaiser Family Foundations (2017).

In her study of risky behaviors among impoverished and socially disadvantaged women in Cleveland, Ohio, Sobo (1995) concluded that people who know about AIDS often act as if they are not at risk, a puzzling discovery that needed explana- tion. AIDS-risk denial, she found, appears to be rooted both in a cultural tradition that values monogamy and personal responsibility and in the actual position of women in society generally and relative to men. Thus, the women whom Sobo studied idealized and desired long-term monogamous romantic relationships and loyal, committed partners. The under - lying cultural logic that supported this heartfelt desire is this: good women get good men, and unworthy women get bad men. If you are a good woman, then you should be able to trust your partner. This attitude reflects very basic cultural ideals in American society and leads people to interpret life course and outcomes in terms of how hard people work and how committed they are to achieving their goals. Simply put, those who succeed are seen as having worked hard, and those who do not are seen as slouches. Having an untrustworthy male partner, in short, implied that a woman did not deserve better, putting her very identity and sense of personal self-worth at risk. Like others in the wider society, the women whom Sobo studied seek good relationships with good men, thereby prov- ing to themselves and their social networks that they are, indeed, women of value. As a result, with their main partners, the women do not use condoms (because as good women they can trust their partners not to have sex with others). One consequence of poverty and social discrimination, however, is that the potential partners whom women like those Sobo studied are likely to meet tend to have comparatively high rates of unemployment and underemployment, lack of health insurance, and limited other resources. As a result of an inability to suc- ceed economically in society and to reap the psychosocial benefits of being suc- cessful in one’s own eyes and in the eyes of peers, it is a special challenge for poor men to feel good about themselves and about their own worth as human beings.

As a psychosocial substitute for economic achievement and hence as a salve for the potential sense of failure in a success-driven society, street culture, in fact, tends to sup- port “sexual achievement”—that is, having multiple partners over time or even at the same time—as a sign of success. Thus, one can still have a sense of achievement in life and the experience of having admira- ble qualities, even if it is acquired through a What Health Anthropologists Do 51 Over time, ethnographic researchers are able to glimpse behind the publi\ c masks and front-stage performances of social actors to backstage and often hid\ den arenas of experience and social interaction. In this way, they are often\ able to develop understandings of behaviors that might otherwise appear irrational, meaningless, or inscrutable, or might otherwise go unknown. For ten years, Andrew McDowell (2016) engaged in the ethnographic study in India of “Bengali doctors,” unregulated popular healers w\ ho do not have medical degrees but make use of biomedical medicines (e.g., inject\ ions and intravenous transfusions of antibiotics, stimulants, painkillers, vitami\ ns, and fever reducers, often in multidrug cocktails). These healers are said by thei\ r biomedical critics to treat immediate symptoms but not underlying disease, potentia\ lly caus- ing longer-term harm to their patients. One of McDowell’s study parti\ cipants was a Bengali doctor named Mohit. He accompanied Mohit on fifty house \ calls to treat patients and spent countless hours with him at his clinic, obse\ rving and chatting about medicine, current events, and their respective lives. McD\ owell found that conversations about Mohit and health were commonplace among the people in southeast Rajasthan, where he carried out this part of his\ research.

He heard such conversations in public places, like the village hand pump\ , bus stand, and squares. McDowell joined these conversations and carried out \ inter- views with seventy local public health providers. McDowell found through his deep and prolonged ethnographic immersion in everyday life and popular health treatment that while Mohit and fellow practitioners treat symptoms, they do so within a cultural frame that is meaningful to\ them and their patients. While their treatment practices may appear irrational in\ the eyes of nonmainstream method, although one that is not entirely beyond the mainstream; fan- tasies of multiple sexual exploits are hardly limited to the poor. Consequently, poor men and women are pushed by social forces and cultural val- ues to be at cross-purposes, a tension that finds expression in high rates of divorce, failure to marry, and intimate partner vio - lence. In their effort to achieve monogamy and the psychological benefit of feeling that they merit a good man, Sobo argues, poor women are pushed to see their male partners as more loyal and more deeply committed than social circumstances allow them to be. Thus, they may begin prematurely to assume that their partners are not seeing other women. In this con- text, the decision not to use condoms affirms a woman’s desire to feel worthy of a dependable man. Various behaviors rein- force this decision. Sobo (1995:99) notes, “A man who gives his wife or girlfriend gifts, services, or money lives up to—or at least begins to live up to and implies he intends to live up to—the cultural ideal of the male partner as breadwinner or provider and as a woman’s protector.” Under these con- ditions, stopping condom use is an act of commitment, an expression of trust, and an investment, through potentially having a child together, in a long-term partner - ship. The problem, however, is that most women who get AIDS are not infected during one-night stands with poorly known sexual partners because condoms tend to be used in such situations. Rather, they are infected with HIV by longer-term partners, people they trust with whom they are hav- ing sex without a condom. 52 Chapter 2 biomedical physicians, they are able to return patients to a satisfying \ feeling that they have a well-functioning body with steady breathing, cycles of hunge\ r and sati- ety, and oscillations between tiredness and invigoration. In short, they\ reestablish a sense of organic and mechanical productivity from the perspective of the\ ir patients, until something else throws their bodies out of their normal cycling pat\ tern.

Complex Sociocultural Tapestries In explaining health-related behavior, health anthropologists pay attent\ ion to the interplay of a wide range of cultural, social, hierarchical, psychologic\ al, environ- mental, and even biological factors. Only by showing how all these weave\ together in complex tapestries, something that the ethnographic methods of health\ anthro- pology allow, can we really understand why people do what they do, belie\ ve what they believe, and get sick or stay well. In thinking about Sobo’s AID\ S study, one advantage of this perspective is the realization that sexual desire—which is often condemned in moralistic discussions of sexual risk—must be reframed “\ from an individual to a collective phenomenon” (R. Parker 2009:xiv). Cultur\ e provides a frame of reference “though which sexual meanings are organized—and\ in relation- ship to which conflicting and contrasting sexual scripts are produced \ and repro- duced” (R. Parker 2009:xiv), and these, in turn, are shaped by othe\ r factors like social hierarchies and inequalities. As this example suggests, health an\ thropology does not provide simple answers to complex problems; rather it provides \ adequate understandings for the design of effective interventions. This aspect of the health anthropology approach can also be seen in its work on a chronic disease like type 2 diabetes mellitus. The word diabetes co\ mes from Greek and in its original form meant “to run through.” The term re\ flects the ancient Greek view that diabetes causes food to rush through the body instead of feeding it, leading the body ultimately to melt down into urine. Today, \ biomed- icine understands diabetes as a breakdown in the body’s capacity to p\ roduce or respond to the hormone known as insulin, producing an abnormal metabolis\ m of carbohydrates and elevated levels of glucose in the blood and urine. \ In recent decades, diabetes has become a global disease that causes suffering, dis\ ability, morbidity, and mortality worldwide, especially in disadvantaged populations.

This development “reflects the evolving global reach of capitalism \ and colonial- ism, which precipitated increased access to commodity foods, decreased r\ eliance on local food sources, and reduced physical activity” (Rock 2005:474\ ). Anthropologists, in particular, have been involved in the study of diabe\ tes in indigenous populations such as American Indians, who often are said to be genet- ically vulnerable to this debilitating condition. Based on ethnographic \ research, health anthropologists have stressed that the high incidence of diabetes\ in indige- nous populations cannot be explained by a case of bad genes. Diabetes appears to be a relatively new health threat to indigenous peoples, the symptoms of\ which do not show up in older accounts, historical records, or people’s memories of prior generations. Rather, diabetes is a disease with social origins and refl\ ects the biolog- ical consequences of intensely adverse structural factors such as povert\ y, discrimi- nation, loss, trauma, and social stress, common threats to indigenous po\ pulations around the world (Ferreira and Lang 2006, Smith-Morris 2006). What Health Anthropologists Do 53 The Health Risks and Benefits of Kissing From a public health standpoint, is kiss- ing risky? If so, what are the known health risks of kissing? Conversely, are there health benefits of kissing? These questions have received increasing attention in public health since the early 1950s when a bacteriologist reported that up to 250 colonies of bacteria can be transmitted during a single passion - ate kiss (fewer if one of the participants is wearing lipstick). To reach this con- clusion, he recruited a sample of adults and adolescents to kiss a sterile glass slide or agar plate for various periods of time. Fortunately, this research found that the vast majority (95 percent) of kiss-transferred microbes are not patho- genic. Since then, of course, HIV/AIDS became a global pandemic and con- cerns about kissing as a route of lethal viral or other microbial transmission have become widespread. In their studies var - ious social scientists have encountered popular uncertainty about kissing as a risk behavior. In one study, for example, researchers conducted semistructured qualitative interviews with thirty-three HIV-infected parents and their children to investigate fears about HIV transmis- sion. They found that many of these fam- ilies reported transmission fears, includ- ing specific trepidation related to blood contact, contact with bathroom items, food sharing, and kissing/hugging. Many of these fears, including those viewing kissing as an HIV risk, are based on mis- conceptions about modes of HIV trans- mission. While kissing is not a very likely route of HIV infection (because HIV can- not survive in saliva), kissing can be a health risk. In fact, an array of infectious diseases can be transmitted through this form of human intimacy, including strep throat, infectious mononucleo- sis (known colloquially as “kissing dis- ease”), Herpes Simplex Virus-2, Hepatitis B, syphilis, scabies (a contagious skin disease caused by a mite), warts, and meningococcal disease (inflammation of the membranes that cover the brain and spinal cord). College freshmen, for exam- ple, especially those who live in dormito- ries, have been found to be at increased risk for bacterial meningococcal disease compared with age mates who are not attending college or living in a dorm set- ting. Moreover, research in Britain found that people involved in intimate kissing with multiple concurrent partners face a risk four times greater of developing meningitis than those not engaged in this behavior. Sexually transmitted diseases such as syphilis also can be transmitted through kissing if syphilis sores are pres- ent in the mouth or lips of one of the par - ticipants. In addition to various diseases, several studies have found that food allergens can be transmitted through kissing. For example, there is a case of a severe anaphylactic reaction in a young woman with shellfish allergies after kiss- ing her boyfriend (who had just eaten several shrimp; Steensma 2003). On the plus side, research shows that there are several notable health benefits linked to kissing, including the fact that kissing, particularly passionate kissing, lowers cortisol levels, an objective sign of stress reduction. Moreover, kissing can improve self-esteem and feelings of being appre- ciated. Further, kissing helps stabilize cardiovascular activity and reduce blood pressure and cholesterol. 54 Chapter 2 Further, health anthropology research in South Africa found that diabete\ s is linked to and adversely interacts with depression, and both are conne\ cted, in turn, to the role of gendered street violence and structural violence\ in creating everyday fear and chronic distress (Mendenhall 2015). Diabetes, in other words, does not develop into epidemic proportions independent o\ f other diseases or taxing social and economic conditions associated often\ with social inequality. As diabetes has gained global recognition as a disease under the global \ influ- ence of biomedicine, researchers have found that it is being used at the popular level as an idiom of distress for talking about suffering and upsetting \ experience as a bodily condition in a culturally meaningful way (Mendenhall et \ al. 2010).

This insight suggests the importance of investigating the relationship b\ etween experienced suffering and distress and the onset of chronic, noncommunic\ able diseases like diabetes. Research Methods Multimethod Research When conducting a study, a health anthropologist or a team of collaborat\ ing researchers generally combines a number of specific methods. This “\ mixed-method approach” often includes direct observation and detailed recording of\ behaviors and events witnessed in the field, as seen earlier in this chapter in \ Brodwin’s (1996) records of folk treatment observations in Haiti. In addition, health ant\ hropolo- gists generally conduct casual interviews with people as they are going \ about their everyday activities, which Pearl Katz (1999) did as she followed surge\ ons around the hospital she studied. Another method frequently used by health anthr\ o- pologists is in-depth interviewing, such as the detailed interviews cond\ ucted by Bluebond-Langner (1996) in her study of cystic fibrosis. To gain a w\ ider contextual framework for understanding what they find in the field, health anth\ ropologists rou- tinely review historic documents or other existing records, such as Harp\ er’s (2002) examination of the historical and economic literature on Madagascar. Health anthropologists also use ethnosemantic elicitation, as well as a set of specialized systematic cultural assessment techniques, such as free list\ s, pile sorts, and Q-sorts, that allow researchers to glimpse how study participants think about and order the components of their world. Pamela Erickson and her colleag\ ues, for example, used free lists and pile sorts, among other techniques, to \ study sexual health and decision making among inner-city African American and Puerto \ Rican young adults (M. Singer et  al. 2006). In this study, called Project PHRESH, eighteen-to-twenty-four-year-olds were recruited through street outreach\ in Hartford, Connecticut, and Philadelphia, Pennsylvania. In small-group settings, they were first asked to list all the kinds of sexual practices that t\ hey knew. Later, in one-on-one sessions, other participants from the same age and \ ethnic groups were asked to sort cards that were printed with descriptions of s\ exual behav- iors that were listed by at least three of the small groups into piles r\ anging from least to most risky for HIV transmission. Participants were then requested to \ explain why they put cards together in the same pile. Using a special set of compute\ r programs What Health Anthropologists Do 55 called Anthropac, the team was able to prepare a scatter plot of the ove\ rall pattern in the sorted cards, based on an assessment of which cards people tended to\ put in the same pile or keep apart in different piles, across all the participants \ in the study. This approach allowed Erickson and coworkers to see underlying cultural assoc\ iations that shape sexual and romantic relations in their study population. Other tec\ hniques com- monly used by health anthropologists include life history interviews, fo\ cus groups, consensus analysis, and diary keeping. One of the concerns of projects like PHRESH is the recruitment of a samp\ le of individuals who represent a larger population when all of the feature\ s (e.g., overall size, makeup of subgroups) of the larger target population are \ not fully known (and hence the recruitment of a statistically representative samp\ le is not possible). One approach that allows the researcher to combine location and time factors to obtain a large, diverse, and reasonably representative sample\ is known as venue-based sampling (VBS). The keys to the VBS approach are (1) \ rigorous exploration of possible recruitment sites (i.e., venues) where members\ of the tar- get population can be found (e.g., a study of street commercial sex wor\ kers might attempt to identify “stroll” sites where commercial sex workers engage custom- ers); (2) focused observation over a period of time at all identified sites to roughly determine the number of individuals from the target group that are found\ at each site; (3) random selection of venues at selected intervals from the li\ st of identified venues; (4) recruitment of individuals at randomly selected venues combined with observation of the number of members of the target group present during \ the time/date of the recruitment; (5) calculation of the relationship of t\ he number of individuals selected from those available at the site during the recr\ uitment epi- sode; and (6) data collection (e.g., through survey, structured inter\ view, in-depth interview) of recruited individuals. As this description suggests, VBS \ combines qualitative and quantitative strategies to provide researchers with confi\ dence that the individuals they collected data from do not represent a skewed sample that differs in significant ways from the larger population of interest.

Examining Lives The life history interview is used to record the life story of an indivi\ dual, with a strong emphasis on the meaning of life events for the person being inter\ viewed.

James Quesada (1998), for example, used this technique to explore the \ effects of war, endemic poverty, political instability, and social despair on Danie\ l, a gangly ten-year-old boy from the central highlands of Nicaragua. Quesada got to\ know Daniel and his mother while studying health and well-being in the afterm\ ath of war in the Nicaraguan town of Matagalpa. Reflecting the growing int\ erest of health anthropology in the health and social effects of war, aggressi\ on, and interpersonal violence, Quesada analyzed Daniel’s life story as an embodiment of the pain and suffering shared by many Nicaraguan children as a result of the U.S.-supported Contra War that had been fought in the area. Daniel succinctly and coolly summarized his grim life experience one day when he told Ques\ ada (1998:60) that sometimes he felt like dying: “Look at me, I’m all bones anyway.

I’m already dying. I’m too small and I have stopped growing and I \ am another 56 Chapter 2 mouth to feed. My mother can’t keep taking care of my brothers and me\ , and I can’t keep taking care of her. I can’t do anything.” Through this single life history, Quesada gained a far deeper understanding of the embodied exper\ ience of war, its profound health costs, the jagged social disruption it bring\ s, and the abject poverty it often produces. Because of Quesada’s intervention, \ Daniel did not die, but there are few Jim Quesadas and many Daniels in the world. In another health anthropology study, Merrill Singer and Rebecca Allen (2017) used a life history approach to address a fundamental que\ stion in contemporary health care: how do we understand and respond to the pressing health problems of society? The conventional biomedical respons\ e to this question involves description of a type of care that is based on\ care- ful clinical assessment of the immediate health factors presented by eac\ h individual patient and the provision of science-based medical treatment drawn from an arsenal of pharmaceutical, surgical, and other established\ and approved biomedical strategies. In subtle tension with this dominant\ clinical model of medicine, the approach known as social medicine places an equal level of focus on the social conditions and structural inequali\ ties that produce and worsen health problems, including social stigmatization\ , adverse physical factors in built social environments (e.g., overcrowdi\ ng, impoverished neighborhoods, and inadequate diets), structural violence (like entrenched institutional racism), and social injustice. These so\ cial fac- tors contribute to a biology of inequality, powered by the ways social d\ is- parity and deprivation get “under the skin” and are inscribed by d\ isease on body systems. From a social medicine perspective, the fundamental under- lying cause of disparities in health are social and economic inequalitie\ s that either produce illness directly or foster unhealthy behaviors that lead to poor health. While there are various personal accounts of the experience of becoming or working as a conventional physician, prospective medical students have few alternative role models of doctors who are not narrowly focused on traditional individual patient/disease-focused approaches to medical practice. Based on extensive life-history interviews over severa\ l months with a social medicine doctor, Singer and Allen present an alter- native model of biomedical practice within the context of the existing structure of twenty-first-century medicine and in light of the consequen\ tial current unequal distribution of health, living and working conditions, a\ nd medical access. The type of social medicine practiced by this physician, which is informed by a keen awareness of the social origins of health an\ d well-being, reflects many of the life experiences he had growing up and \ the identifiable influences of various friends, family members, and mentors as well as his often troubled experiences with powerful medical institution\ s.

Focus Group Interviews Originally developed by social scientists, focus groups came to be a favored tech- nique of market researchers concerned with assessing the appeal of new products among consumers. In more recent years, anthropologists and other social scientists have readopted focus groups and used them to study many issues, including health. What Health Anthropologists Do 57 Focus groups entail bringing together a group of people and stimulating them to engage in conversations about issues of research and community interest. With this goal in mind, for example, researchers investigating a topic of concern among many Native Americans (Bletzer et al. 2011), alcohol consumption, organized focus groups with members of five tribes from southwest, northwest, and northern plains to discuss this issue. They then used the performance of humor as a stylistic feature of the conversations to explore aspects of adolescent and adult drinking with the insight that how social groups create and use humor is a serious issue for cultural analysis. The researchers found that the most common forms of humor in the con- versations were parody, hyperbole, and word play and that all of these contributed to the ability of the group to discuss a highly sensitive topic. Interpretation of focus group data requires the systematic review of conversational transcripts to identify themes that can be developed and configured, in collaboration with community members, into effective program initiatives. In this instance, appropriate use of humor was found to be an important entrée into collaborative exchange, a lesson for culturally sensitive inter vention. Discovering behavioral practices like this allows health anthropologists\ to design health-related interventions that are grounded in actual beliefs \ and behaviors.

Considering Consensus The term consensus analysis refers to a quantitative procedure used to determine the modal (i.e., most frequent) answers provided by a group to a set of qu\ estions about a particular topic (e.g., “what is a cold?”). Use of consensus ana\ lysis allows researchers to determine the degree of cultural agreement in a group or between subg\ roups of a larger population. For example, asthma beliefs and practices have been f\ ound to vary among ethnic groups. One important variation related to ethnicity is the different descriptors used to express an asthma attack. These descriptions can be \ both physical and psychological in nature. In a multicity cross-cultural comparison of\ four different Latino groups in the United States, Mexico, and Guatemala, health anthro\ pology researchers found broad agreement about the major respiratory signs of a\ sthma, including wheezing, cough, chest noise, and fast or difficult breathin\ g (Pachter et al.

2002). Particular to Puerto Ricans in the Hartford, Connecticut, sample\ , however, was reference to symptoms such as chest pain; decreased activity; increa\ sed blood pressure; chest congestion; fast heartbeat; red, tired, or dark eyes; and difficulty breathing or talking to describe asthma attacks. Because these latter sy\ mptoms were peculiar to one group, they cannot be considered part of a pan-Lati\ no cultural complex. Rather, they are core elements of only a Puerto Rican cultural \ conception of asthma. Failure to understand this kind of information can lead to pu\ blic health efforts that are overly generalized and thus fail to be effective with s\ pecific popu- lations, such as Spanish-language prevention materials that assume that \ the term “asthma” means the same thing to all Latinos.

Doing Diaries Diaries commonly are thought of as very personal records of one’s tho\ ughts, feel- ings, experiences, and relationships, but they have been drafted into th\ e study of 58 Chapter 2 health as well. Researchers studying issues such as drinking behavior, f\ ood intake, and sexual risk have employed diaries as a means of getting insider desc\ riptions of behaviors and experiences as soon after they occur as possible (when me\ mories are at their best). In a study of access to sterile syringes, for examp\ le, a team of health anthropologists, epidemiologists, and other researchers recruited a small sample of active illicit-drug injectors in three cities in New England t\ o record their acquisition, use, and discard of syringes in a daily diary. For example, one of the participants in the study recorded the following information in h\ is diary: [Thursday] 4-13-00 Went to cop [acquire drugs] last night, nobody was ar\ ound.

So we went all over and found some [drugs] finally. Me and John used tha\ t one needle I have. It’s really messed up. But after 20 minutes of trying \ he shot me with 3 bags [injected me with the drugs from three small plastic bags]. \ He then used my works [syringe]. He didn’t clean them or anything. My works a\ re bad.

The tip is all bent.

Fri. April 14th. The works wouldn’t draw up the dope so we were going to put some cream on the black tip [the syringe plunger] so it wouldn’t jam up and [would] slide easier. We continued to have the problem of the works \ not drawing up. They’d start sucking up the dope then would stop. Finally\ it sucked everything from the spoon and he hit [injected] me . . . the works are in bad shape. So it takes him longer to get it in the vain [vein]. But he final\ ly did then we shared spoon and cotton [to filter the drug mixture] and works and he\ did himself next which took a while too because the shape of the needle. It has a burr in it. But we did it.

Through accounts of this sort, the study (Stopka et al. 2004) found that drug users’ diaries elucidated useful information on (1) daily patterns \ of injection drug use, (2) the social contexts of high-risk events, (3) HIV and hepati\ tis risk related to the street life cycle of a syringe, and (4) emotional correlates of dr\ ug use. Further- more, the study discovered an unexpected intervention effect that keepin\ g a diary may have in the lives of drug users: a number of the individuals who kep\ t diaries approached the researchers seeking help. Being pushed into paying closer\ attention to the impact of drugs and the frequency of risk in their lives, they de\ cided to get into drug treatment. Assistance into treatment was readily provided. As \ this exam- ple shows, health anthropology research itself can offer a form of inter\ vention or serve as a model for new intervention approaches in public health. Quantitative Methods In addition to these qualitative research strategies, health anthropologists use various quantitative techniques, such as the sur veys Kendall (1998) used to assess people’s beliefs about dengue in Honduras, described in chapter 1. Qu\ alitative methods can be used, in fact, to improve the quality of quantitative data. In a project focused on the traumas endured by Cambodian refugees in the United States (Hinton et  al. 2015), researchers began by developing an understanding of somatic symptoms and culturally meaningful syndromes. This was done using qualitative inter views with Cambodian patients at a clinic, as well as through con- versations with Cambodian monks, traditional healers, and community lead\ ers. What Health Anthropologists Do 59 Based on the information that was collected, the ethnopsychological condition known as kut caraeun, which translates into “thinking a lot” (TAL) or “thinking too much,” was identified as an important idiom of distress (a concept discussed in chapter 1) among Cambodian refugees. Suffering from TAL involves rumination about unpleasant topics, such as enduring a loss, suffering a setback or failure, or struggling with a current life concern, to the point of experienced distress. Symp- toms of this condition include fear and anxiety, agitated irritability, depression, shortness of breath, insomnia, heart palpitations, neck soreness, and dizziness. As part of a broader mental health assessment with two hundred treat- ment-seeking adult Cambodians in a psychiatric clinic in Massachusetts, \ researchers administered several TAL instruments, including a culturally salient che\ cklist of expe- rienced TAL symptoms and a questionnaire that measured the severity of TAL and of TAL-induced distress. Based on the findings, the researchers argue \ that explo- ration of this idiom of distress provides important clinical insight int\ o local social concerns, the experience of trauma, and Cambodian ideas of ethnopsycholo\ gy. This type of information, they maintain, is critical for the evaluation of ps\ ychological distress and the development of contextually sensitive interventions.

Broader Collaboration Health anthropologists now collaborate with a broad range of other types\ of researchers. For example, a number of health anthropologists work with l\ ab- oratory scientists and collect biological specimens, such as the urine s\ amples described in chapter 1 that were collected by Thomas Arcury and coworkers (2005) among farmworkers to test for pesticide exposure. Multidiscipli\ nary col- laboration of this sort is now quite common in health anthropology. As the global health impacts of climate change have become increasingly \ clear (Baer and Singer 2014), health anthropologists have begun to col\ laborate with climate scientists, health-care professionals, community activists,\ and other concerned individuals. Some of this collaboration has developed through \ anthro- pologists becoming involved in grassroots climate action groups and the \ larger climate social movement that promotes social, economic, and technological changes designed to mitigate climate change and its damaging impacts. No\ tably, one of the cofounders and cochairs of the 2017 March for Science—organized in protest of the Donald Trump administration’s attacks on science, i\ ncluding climate science—was anthropologist Valorie Aquino. Interdisciplinary \ research on climate change and health is another way health anthropologists have partic- ipated in collaborative efforts in climate change mitigation.

Health Anthropology in Use Mobilizing Research Findings Beyond research, health anthropologists commonly are concerned with appl\ ica- tion, that is, with the practical use of their research-gained knowledge\ and expe- rience-gained skills. Application in health anthropology takes many form\ s. Health anthropologists, for example, have carried out research on the lived exp\ eriences of women to help reduce the barriers they face in accessing reproductive he\ alth care. 60 Chapter 2 This can lead to meaningful policy or programmatic changes that improve \ access to needed services (e.g., Ostrach and Matthews 2015). Ethnographic res\ earch has shown that in some settings access to health services is encumbered by s\ treet-level bureaucrats, such as security guards and nurses, or by strict bureaucrat\ ic adherence to official procedure. These barriers can override the clinical needs \ of patients in ways that actively harm their health. To overcome such barriers faced by indi\ genous Maya patients in rural Guatemala, Anita Chary and colleagues (2016) worked with Wuqu’ Kawoqm, the Maya Health Alliance, a nongovernmental organization in Guat\ emala, to develop and implement a patient accompaniment program. This intervent\ ion helps Maya patients with limited Spanish language abilities and low lite\ racy to suc- cessfully navigate hospital environments and gain access to needed care.\ In a very dif- ferent type of applied project, researchers worked with local, small-scale gold mining communities in Peru to develop safe technologies for gold extraction (B\ audin et al.

2016). This is of critical health importance because mercury has long b\ een used by gold miners because it can be mixed with gold-containing rocks to form a\ n amal- gam, which, when heated (and the mercury vaporized) releases the desir\ ed gold.

But mercury vapor is highly toxic to all body systems at even minute lev\ els of expo- sure. To ensure that the new, safe technologies would be acceptable to t\ he miners, the researchers worked closely with them at all stages of design. Miners tested and provided feedback on the various extraction prototypes they were shown a\ nd were pleased with the final models. In this instance, a participatory appli\ ed approach was used to prevent health problems and diminish environmental pollution. Applied health anthropologists are also involved in the direct delivery \ of health care to communities in need. An example, from Haiti is the collaboration\ between HOPE (Health Opportunities for People Everywhere), an international he\ alth orga- nization that provides humanitarian assistance, and Koodinasyon Gwoupman\ Pey- isan Borgne, a Haitian peasant community development organization (Mazz\ eo et al.

2013). Applied anthropologists working with HOPE observed firsthand t\ he positive transformations achieved through community-based peasant development act\ ivities.

Their research helped to guide the work of HOPE with local partners to i\ mplement a range of projects, including health-care and sanitation interventions.\ These were of vital importance because a deadly cholera epidemic broke out in Haiti\ in 2010.

The extensive, capillary-like social network developed by Koodinasyon Gw\ oupman Peyisan Borgne served as a model for the mobilization of volunteers in t\ he fight against the cholera epidemic. Recognizing the importance of social networks in addressing health issue\ s has been an integral component of the approach of many applied health anthro\ pol- ogists. The value of a medical health anthropological focus on social ne\ tworks in the AIDS pandemic (as opposed to one-on-one prevention education models\ that focus on individuals) was demonstrated in the work of Robert Thornton (\ 2008) in sub-Saharan Africa. Thornton was particularly focused on sexual networks, which he noted are invisible even to the people who participate in them (in t\ hat people know who they have had sex with but not all of the people their partners\ have had sex with, and certainly not all of the people their partners’ partner\ s have had sex with). Thus, he referred to sexual networks as unimagined communities. Yet, in sub-Saharan Africa, where sex is the dominant route of HIV transmission,\ sexual networks are absolutely critical to whom, to where, and to how quickly H\ IV spreads. What Health Anthropologists Do 61 Indeed, it became Thornton’s view that it was precisely because they \ focused on individuals and not on sexual networks that many AIDS education campaign\ s had little effect in slowing the epidemic in many places. The AIDS preventio\ n effort in Uganda, where Thornton did his research, was comparatively successful, b\ y contrast, because the population is largely rural and dispersed, socially segmente\ d by class, ethnicity, and religion, and not particularly mobile. Moreover, the coun\ try was hit early and hard by AIDS. Noted Thornton (2008:231): “All of these fa\ ctors had the effect of eliminating links between clusters of previously sexually link\ ed people, and the whole [sexual] network collapsed. HIV was no longer transmitted effi\ ciently throughout the network, and HIV prevalence fell dramatically.” Based \ on his analy- sis of the AIDS epidemic in Uganda and South Africa, and the behaviors t\ hat occur in sexual networks that promote the spread of HIV, Thornton recommended \ that effective HIV/AIDS prevention should (1) encourage people to limit the\ mselves to one sexual partner at a time (as having concurrent sexual partners with\ people who also have multiple concurrent sexual partners facilitates the rapid spre\ ad of the epi- demic), (2) promote the idea that at the end of a sexual relationship\ people should refrain from having new sexual partners for at least one month (because people are most likely to infect others in the first month or so after they becom\ e infected), and (3) uphold the idea that people should avoid sex when traveling away f\ rom home (which would slow the ability of the virus to jump to new areas). As these examples show (and a very long list of additional examples cou\ ld be cited), health anthropology is not isolated in the ivory tower of ac\ ademia.

It is being used daily in numerous places around the world, from the mos\ t remote villages to the largest and most technologically advanced megalop\ o- lises, to address health-related problems of many kinds, such as community nutrition education (figure 2.1). Very likely, there is a health anthropologist working in the city or town where you live (or at least nearby), attem\ pting to use anthropological skills to address real-world health problems. Finall\ y, not all of applied health anthropology is a post hoc product of a research p\ roject.

Health anthropologists also design and oversee intervention programs, ev\ aluate the effectiveness of programs, and are involved in helping to establish \ and use ethical standards in health-care decision making.

The Health Anthropology Crystal Ball What is the future of health anthropology? Where is the field going? H\ ow might it change over the coming decades? As jocosely summarized by Danish physici\ st Niels Bohr: “Prediction is very difficult, especially if it’s about th\ e future.” One thing, however, is clear: as Nancy Scheper-Hughes and Margaret Lock (1987) ar\ gued some time ago, it is a fallacy to believe we will discover a narrow biotechno\ logical salvation or magical medical bullet to solve all of the many old as well as emergent health and social problems faced by humankind. Human health problems reflect huma\ n social life and social interactions with the environment, and thus addressing h\ ealth issues means knowing about the details of the social structural, environmental,\ and cultural aspects of the human condition. Herein lies an ongoing role for health a\ nthropology.

Without question, health anthropology also will be shaped by the social \ and physical worlds of the future. That future, as Yogi Berra once quipped, “ain’t what it used 62 Chapter 2 to be.” This is particularly true with reference to health. One of th\ e reasons is the impact of ecobiosocial changes taking place on planet earth. A second reason has to do with the configuration of the social worlds we are constructing. As a result of these changes, in addition to many of the current areas of focus, health anthr\ opologists of tomorrow will be progressively more concerned with issues such as the\ following factors. First is the far-reaching and increasingly faster pace of globalism, whi\ ch facil- itates the global spread of diseases around the world (e.g., diabetes). Globalism also contributes to the restructuring of local social contexts and ways \ of life in ways that create or enhance health vulnerabilities. One critical factor \ in this regard is what have been termed “killer commodities,” that is, global pro\ ducts distrib- uted around the world for a profit that cause harm to consumers because they are physically dangerous or contain toxic substances. Linked to killer commo\ dities is the growing rate of dumping in underdeveloped countries of damaged, used\ -up, and otherwise discarded consumer products by the developed world. Second, anthropogenic climate change has multiple and diverse impacts on the environment. At the same time, the earth is beset by multiple other forms of environmental degradation, including air pollution, depletion of edible ocean FIGURE 2.1 Dietician speaking about healthy eating at a community health education \ pro- gram organized by medical anthropologists and colleagues. Photo by Merrill Singer. What Health Anthropologists Do 63 fish stocks, acid rain, loss of wetlands, pesticide and other chemical\ pollution, salinization of agricultural zones, ocean acidification, deforestation\ , and loss of biodiversity through extinctions. It is likely that over time a growing \ portion of the toll these changes take on human health will be due to ecocrises interactions that multiply adverse effects. Third, the world now faces a global refugee problem, and human migration\ generally is reshaping the distributions of populations globally. With m\ ass human movement, which often occurs under less-than-optimal conditions, comes s\ ignif- icant risks for disease, injury, mistreatment, and death. Citizen resist\ ance to the provision of refugee aid can produce tense border conditions and punitiv\ e policy changes. Yet wars, changing environmental factors, and economic conditio\ ns are likely to continue to promote human movement, creating the need for cult\ urally sensitive understandings and responses to avoid catastrophes. Fourth, growing barriers to access to food or ways to produce it and pot\ able water are already significant sources of disease and death in many parts of the world, and the impact of these factors on human health is likely to grow worse as a result of climate change, other anthropogenic environmental degrada\ tions, and displacements and disruptions of human communities. Fifth, the level of threat from infectious disease in the twenty-first\ century affirms that our world is very different from what health experts in t\ he not- very-distant past imagined it would be. Globally, infectious diseases today are a leading cause of death, even in highly developed nations. Witness the SA\ RS epi- demic in 2003, the H1N1 influenza pandemic six years later, followed b\ y the Ebola epidemic in 2014–2016, and the 2015–2016 Zika epidemic. The \ rapid emergence of new and renewed pathogenic sources of human disease, includ\ ing growing drug resistance among pathogenic microorganisms, has become a ma\ jor threat to the future of human health. Sixth, the adverse syndemic interaction of diseases, both acute and chro\ nic, and somatic, emotional, and behavioral in nature, is intensifying the im\ pact of diverse threats to health. While syndemics increasingly have come to be rec- ognized as a significant aspect of the contemporary health profile, \ especially of impoverished, disadvantaged, marginalized, and oppressed populations, mu\ ch remains to be learned about the nature of the interactions that occur am\ ong comorbid diseases and between adverse social conditions and patterns of \ disease clustering in affected populations. Seventh, global health increasingly will be shaped by the urbanization of the human population, including the rapid growth in size and number of megac\ ities with more than ten million residents, including an ever-growing number o\ f highly vulnerable, densely concentrated, underserved, and poorly housed mar- ginalized peoples. Eighth, the development of the “profitable body,” associated biotechnolo- gies, and tissue commodification (e.g., organ selling by the poor) a\ re reshaping human health and the social distribution of suffering. At the same time,\ the global distribution of pharmaceutical drugs has led to the use of these \ substances in ways that go far beyond their intended or allowable purposes. In addi\ tion, the global pharmaceutical industry, in all of its activities, from bioprospe\ cting and the commercialization and patenting of traditional medicines, to clinica\ l trials 64 Chapter 2 in developing nations, to the operation in local environments of manufac\ turing plants, is having increasingly dramatic global health impacts. Finally, in coming years, mounting global tensions stemming from the gro\ wing demands of an expanding global population, unequal distribution of resou\ rces, and the dwindling availability of natural resources (e.g., peak oil extract\ ion will occur during this century and then production will decline), as well as clima\ te change, are expected to intensify the frequency of war and group violence. Conse\ quently, the level of carnage to be produced by future wars—including both the\ number of battlefield casualties caused by ever-enhanced armaments and the fact \ that modern warfare increasingly targets civilians through sexual crimes, community destruction, torture, mass displacements, malnutrition, and ethnocide, as well as thr\ ough the spread of infectious diseases—is likely to set new historic records. In short, the tremendous need for socially, culturally, and environmenta\ lly grounded understandings of the construction of human health and illness,\ and health interventions informed by these understandings, will continue to \ grow in the future, and in fact, may become much more urgent. As expressed by João Biehl and Amy Moran-Thomas (2009:282), “Continually adjusting itsel\ f to the reality of contemporary lives and worlds, the anthropological venture ha\ s the potential of art: to invoke neglected human possibilities and to expand \ the limits of understanding and imagination.” At the same time, health anthropol\ ogy has demonstrated its ability as an applied field to address pressing probl\ ems of human suffering in a world in which most of our afflictions involve a comple\ x interface of sociocultural and biological factors, and in which social, economic, and\ political inequality are the primary forces threatening our species and our planet\ .

Discussion Questions 1. Anthropologists often stress the importance of culture in under - standing human behavior. In her study in Madagascar, Harper found that there was something more im- portant than culture. What was it and what do you think about her argument?

2. What were some of the key find- ings of Pearl Katz about “surgeon culture,” how was she able to make these findings, and what was their practical value?

3. The chapter identifies eight things that health anthropologists do.

What do you think are the three most important things they do and why?

4. How have health anthropologists responded to the ever-increasing importance of electronic commu- nication in people’s lives?

5. Why might people choose risky behavior?

6. What has been the anthropolog- ical approach to addressing the high rate of diabetes in many in- digenous and ethnic minority populations?

7. Why do health anthropologists emphasize the importance of so- cial networks?

8. Health anthropology does not provide simple answers to com- plex problems; instead it provides adequate understandings for the design of effective inter ventions.

Discuss this statement and its implications. 65 3 I am interested in physical medicine because my father was. I am inter- ested in medical research because I believe in it. I am interested in ar\ thritis because I have it. —Bernard Baruch, New York Post, May 1, 1959 Introduction and Overview T his chapter addresses some of the core issues and challenging questions \ en- gaged by health anthropology. What does it mean to be healthy or sick an\ d who determines a person’s health status? What is the relationship of \ culture to health, to illness, and to patterns of mortality? Is there a difference between hav- ing an illness and having a disease? What does cure mean? What are the varieties of health care and healers cross-culturally? In this chapter, we define key concepts and attempt to answer questions like those listed here. In this way, we \ further clarify the way health anthropologists look at and respond to health pro\ blems in the communities where they study and work. Conceptions of Health and Illness Defining Terms Health anthropologists have devoted considerable energy to examining con\ cep- tions of health and illness cross-culturally. While health and illness are everyday terms, what do they actually mean? Like many words in common use, a clos\ er examination shows that they are often much more complex and much more loaded with cultural content than is at first evident. In what is now a classic and widely referenced (and debated) definit\ ion, the World Health Organization (WHO; 1978) designated health as “not mer\ ely the absence of disease and infirmity but complete physical, mental and soc\ ial wellbe- ing.” This enduring characterization is appealing because it stresses\ that health is not simply a biological state; it reflects a unity of mind and body\ , and, more- over, it is deeply interconnected with the quality of social relations a\ nd social conditions. Nonetheless, it is evident that this definition is somewha\ t utopian.

It is unlikely that many people in the world would be found healthy in t\ erms of this definition. An important distinction has been made between experiential health and functional health (Kelman 1975). The former refers to a sense of wellness, an experience of tranquility and fulfillment through social accomplishments. Understanding Health, Illness, and Disease 3 CHAPTER 3 UNDERSTANDING HEALTH, ILLNESS, AND DISEASE 66 Chapter 3 The latter is what employers expect from their workers to ensure perform\ ance levels essential to capitalist production or perhaps what professors exp\ ect from their students in showing up for classes and examinations. Even though e\ mploy- ees or students may not quite feel like going to work or showing up for \ a 9:00 a.m. lecture, they are deemed functionally healthy if they do so, even if it requires several cups of coffee, an “energy” drink, or other stimulants. As\ an alternative approach, critical health anthropologists define health in terms of ac\ cess to and control over the basic material and nonmaterial resources that sustain a\ nd pro- mote life at a high level of satisfaction. In truth, health is difficult to precisely define because the term e\ mbodies cultural value judgments about what is a desired state of being, and bec\ ause the notion of health is deeply rooted in cultural metaphors. Metaphors are p\ ervasive in everyday language and thought. For example, in capitalism, an economy\ is viewed as healthy if it is growing while money is called the lifeblood of society.

In the domain of a person’s state of being, health is metaphorically \ equated vari- ously with goodness, moral purity, divine favor, or living the “right way.” In each of these cases, ideas about health are imbued with values that reflect\ underlying worldviews. Growing up in a particular society, we commonly internalize \ its key metaphors and may not realize that they are cultural constructs or that they have a lot of influence on us, intellectually, emotionally, and even physic\ ally. Yet, metaphors provide us with a mechanism for thinking and communicating sim\ ply about very complex and opaque issues of profound concern. Whatever one’\ s per- spective, it is evident that health is a hard-to-define elastic condit\ ion that is best understood within an encompassing sociocultural and historical context. The terms disease, illness, ill health, and sickness are often used interchange- ably in everyday speech, but much ink has been spilled trying to use the\ m as technical concepts with specific meanings. Biomedicine has depicted disease as a maladaptive state, particularly in terms of the environment. For example\ , long ago, William White, in The Meaning of Disease (1926), emphasized that during a disease an organism, at least temporarily, is fighting a losing battle\ with tempera- ture, microorganisms, disappointment, or other environmental foes. George Engel (1962), who is often credited as having fathered the biopsy- chosocial approach in biomedicine, asserted that “When adaptation or \ adjust- ment fail and the preexisting dynamic steady state is disrupted, then a \ state of disease may be said to exist until a new balance is restored which may a\ gain permit the effective interaction with the environment” (quoted in Cl\ ouser et al.

2004:92). As suggested by these comments, biomedicine understands disease as a sub\ - optimal or abnormal condition, a disorder of a normal structure or funct\ ion of the body or mind, that affects part or all of a person or other organism and is expressed through specific signs and symptoms.

Differentiating Disease and Illness The meaning-centered perspective in health anthropology posits a distinction between disease and illness, with the former constituting a natural enti\ ty that can Understanding Health, Illness, and Disease 67 be identified through various bodily signs, such as a high temperature\ , elevated blood pressure, or rapid heart rate (figure 3.1), and (possibly but\ not always) a sense of physical and emotional discomfort (Kleinman 1980). The presen\ ce of a disease, in other words, is established through a diagnosis by a profe\ ssional healer, like a physician of biomedicine. A disease label (e.g., diabetes) is a unit for asserting why someone got sick and specifying what condition they are su\ ffering from. The recognized diseases of biomedicine are codified in the Inter\ national Classification of Diseases (ICD; World Health Organization 2017a). T\ his cata- log includes places for hundreds of distinct conditions. Carpal tunnel s\ yndrome, for example, occupies code G560 while Ebola sits at code A984. The ICD i\ s designed to be both “exhaustive—to include all conditions—and t\ o ensure that no particular event of sickness will be classified under more than one\ code num- ber” (Hahn 1995:18). In other words, as reflected in the ICD as well in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 2013), biomedicine conceptualizes diseases as (1) discret\ e entities (each disease, be it cholera or paranoia, is assumed to be an objective\ entity found in nature and not just a product of human attention) and (2) cl\ inically identifiable and hence a boundable item in the world. Normal practice \ in bio- medicine, whether in its diagnostic, research, or treatment capacities, \ is guided FIGURE 3.1 Screening for high blood pressure. Photo by Merrill Singer. 68 Chapter 3 by the conceptualization of diseases as distinct, unique, and disjunctiv\ e entities that exist (in theory) separate from other diseases and from the socia\ l groups and social contexts in which they are found at any point in time. Illness, by contrast, as it is often used in health anthropology, consti\ tutes a cultural construction that can be identified only through interpretive\ activities or narratives. Illness is rooted in a culturally constituted explanatory\ model that seeks to clarify the source of distress and to outline a course of treat\ ment to be pursued by both the healer and the patient. Even an event as simple as a\ cough takes place in historic and cultural context: Illness depends on relatively stable biological features—a cough in e\ very culture uses the same muscles and respiratory organs—but it is also deeply hi\ storical, no less changing than the microbes that surround and interpenetrate us. Indeed, the country of the ill assumes the distinctive features of whatever nati\ on or social group inhabits it. (Morris 1998:22–23) As discussed later in this chapter, healers and patients, such as the curandera (Hispanic folk healer) and her patient seen in figure 3.2, may reach\ different conclusions about the nature of a patient’s health problem, with vary\ ing conse- quences for healer-patient communication and relationships and patient a\ dher- ence to healer instructions. FIGURE 3.2 Maria Ruiz Mendoza, a Zapotec healer (curandera) from Teotitlán del Valle, Oaxaca, Mexico, treating a child for “anginas” with a tomatillo coated with salt. Ph\ oto by Liz Cartwright. Understanding Health, Illness, and Disease 69 Reconceptualizing Disease and Illness There has been a tendency in health anthropology to use the term disease for the biomedical diagnosis of sickness and to reserve the term illness for both the lay, folk, or popular healer’s definition and the patient’s unde\ rstanding of his/ her sickness. However, we suggest that the term disease refers to the diagnosis of a sickness made by a biomedical physician or some other type of profe\ ssional- ized heterodox medical practitioner, such as an Ayurvedic physician in I\ ndia or a chiropractor or naturopath in a Western society. Within this scheme, t\ he term folk disease (or more accurately, folk illness) refers to the folk healers’ lab\ el for a sickness, such as susto, a label used by curanderos in Latin American cultures for the distress that a person may experience following a frightful experience. Illness refers to the patient’s experience of sickness and the understandings\ of the mem- bers of the patient’s immediate social network. The social stature of a healing tradition is a critical component of its\ ability to shape disease conception. Most diseases or illnesses are self-limitin\ g for rea- sonably healthy individuals. Conversely, chronic diseases endure, often \ with great physical cost to the patient. Ultimately, of course, all bodies die unde\ r the weight of diseases, traumas, or other factors. Thus, death has been called the great equal- izer, and this idea was even enshrined in a medieval European ritual kno\ wn as the Dance of Death. It involved a processional through churchyards and cemet\ eries led by a figure macabrely dressed as a hooded skeleton. This ritual ha\ s been ana- lyzed as an expression and enactment of deep collective anxiety under de\ sperate social and economic conditions and recurrent deadly epidemics of the pla\ gue.

In one very important sense, however, death is not the great equalizer: when you die, the conditions under which you die, what you die from, and the amou\ nt of suffering you endure before you die is very much a reflection of signi\ ficant social disparities within and across societies. Death comes to us all, but the \ nature of its actual occurrence is the embodiment of inequality.

Understanding Cure Biomedical practitioners often ascribe “cures” on the part of eith\ er professional- ized heterodox practitioners or folk healers to the placebo effect. This\ has been defined as any therapeutic procedure (or a component of any therapeutic procedure) which is given (1) deliberately to have an effect, or (2) unknowingly and \ has an effect on a symptom, syndrome, disease, or patient but which is also used as an\ ade- quate control in research. The placebo effect is defined as the changes \ produced by placebos. (Shapiro 1964:713) In fact, as numerous studies have indicated, the placebo effect occurs w\ ithin all medical systems, including biomedicine, as randomized double-blind tests\ on drugs have repeatedly demonstrated. This is something that at least some\ bio- medical physicians recognize as they seek to meet patient expectations. The term placebo is Latin for “I will please.” 70 Chapter 3 One schema developed by a health anthropologist delineates three human responses to sickness: (1) autonomous responses, or “all those proc\ esses which the organism can invoke to gain health or equilibrium, including the var\ ious immunological and related systems”; (2) specific responses of the\ body to treatment, be it an administration of a medicinal herb or penicillin; an\ d (3) meaning responses, or the “psychological and physiological effects of\ meaning in the treatment of illness” (Moerman 2001:14). The meaning response t\ ends to encompass most situations that have been generally associated with the p\ lacebo effect, whether it is the cure that a patient experiences after taking a sugar pill or the impact of a healing ritual conducted by indigenous practitioners \ of the kinds that we discuss in chapter 6. The placebo effect suggests that the\ subjective understandings and responses of patients to the treatments, rather than \ just the objective biological impact of treatments, play a role in patient recove\ ry or dete- rioration. In biomedicine, for example, the conditions, procedures, and mate- rials of treatment are meaningful to patients; they represent the healin\ g power ascribed to this medical tradition:

Clinicians often dress up in special uniforms that convey power and authority.

They have very expensive machines that can look inside your heart or bra\ in. All this, plus the magnificence of the hospital building . . . , the decor of the of- fice, the lights of the operating room, the computers on every lap, the \ magical prescription pad, and the caring nurse, piles up meaning with increasing\ power regardless of what may be in the capsule or syringe. These meanings create ex- pectations that can dramatically modify the effectiveness of even the most pow - erful proven treatments. (Moerman 2011:172) Folk Understandings Anthropologists have observed that peoples around the world operate with\ a wide array of definitions of health and illness, most of which tend to\ reflect core themes of their underlying culture or contact with other groups (E\ rick- son 2008). The James Bay Cree, for example, a traditionally foraging so\ ciety in subarctic Canada, view health (miyupimaatisiun) as a balanced relationship between individuals and their sociocultural and natural environments. Am\ ong the Cree, health “implies proper hunting practices and hence a respec\ tful rela- tionship between humans and the animals of the land: a successful hunt m\ eans healthy eating and appropriate social relations means that the hunted fo\ ods will be apportioned amongst oneself and one’s kin” (Adelson 2003:617)\ . The James Bay Cree operate with two categories of illness: those indigenous to the\ ir culture and those that they adopted (and adapted) as a result of their contact\ with Euro- peans. Half a world away from James Bay, the !Kung San of the Kalahari D\ esert in southwestern Africa interpret the ability to sweat as an indicator of good health since sweat is regarded to be a life-giving substance. The Matsigenka, a\ people in the upper Amazonian rain forest of southeastern Peru, a group with a \ mixed economy consisting of fishing, hunting, gathering, and horticulture, u\ se the term shinetagamtsi to refer to a sense of contentment, productivity, being well fed, and freedom from illness. Understanding Health, Illness, and Disease 71 To cite one additional example, in their traditional culture, the Han, b\ y far the numerically and politically dominant ethnic group in China, define\ d health as a harmonious relationship between humans and the cosmos and among humans\ themselves. A healthy body is one in which Qi (a form of energy that pe\ rme- ates the universe), blood, vital essence, body fluid, and nutrients a\ re in careful balance. An imbalance results in illness and may emanate from a wide array of factors, including wind, cold, heat, damp, dryness, fire, epidemics, e\ motional turmoil, improper foods, stress, physical injuries, parasites, and blood\ stagnation.

As these examples suggest, popular understandings of health vary, but, a\ s health anthropologists long have emphasized, to understand them they must be st\ udied within social and cultural context; health, as people know it, is always\ entwined with other key themes and structures of society. This is true for colleg\ e students as well. Abusive drinking on and near college campuses produces disturbi\ ng pub- lic health statistics about alcohol-related student deaths, injuries, sexual assaults, and negative academic performance, yet efforts to control campus drinkin\ g often are resisted by students who see it as an infringement on their rights and faculty who oppose policing students. This response indicates that alcohol-enhanced partying and even binge drinking on campus are enmeshed in strongly held\ cultural values. Understandings of Disease Causation As they vary in their understandings of health, societies also differ co\ nsiderably in terms of what they regard to be the causes of illness. The Yanomamo, horti- culturalists in the Amazon basin of Venezuela and Brazil, for example, b\ elieve that virtually all illnesses are caused by spirits or ghosts of their an\ cestors. Con- versely, the Indians of the northwest coast of the United States traditi\ onally identified several causes of disease, including soul loss, sorcery, ta\ boo violation, disease-object intrusion into the body, and spirit intrusion. Table 3.1 \ summa- rizes many of the diverse theories of the causes of disease or illness (\ depending on whether a healer or a layperson makes the diagnosis) encountered by \ health anthropologists in their research. Beyond the alternatives listed in the table, many societies employ a “\ humoral system” of health and illness of one sort or other. A humoral medical\ system is organized around the premise that the organs, body systems, and fluids\ inside the body parallel elements and structures of the natural world outside t\ he body. For the ancient Greeks, for example, the bodily “humors” of phlegm\ , yellow bile, black bile, and blood were believed to reflect the natural eleme\ nts of air, water, earth, and fire, respectively. Maintaining good health, the anc\ ient Greeks believed, depended on preserving a balance of the humors. When a person became ill, Greek healers would drain surplus humors by purging the dige\ stive tract or through bloodletting. These therapies were believed to help res\ tore a balance in the body’s humors. The three major humoral theories found in the world today are traditional Chinese healing, Ayur vedic medicine of South Asia, and the Latin American system, which has its historic roots in ancient Greek and other Mediterranean civilizations. Guatemalan Indians, for example, whose pre-Columbian beliefs 72 Chapter 3 were reshaped following colonial contact with Europeans, generally acknowledge four causes of illness: natural injur y such as snakebite, internal bodily imbalance, intrusion of pathogens, and witchcraft. Like other Latin American peoples, they believe that excessive consumption of “hot” foods (e.g., bea\ ns, beef, and chicken) or “cold” foods (e.g., corn, eggs, and oranges) can result in chills and coughing. The categories of “hot” and “cold” refer not necessarily to the actual physical temperature of a food or location but rather to its qualities and effects on the body, and the categories often var y from group to group in Latin America. Humoral systems are not the exclusive domain of peasant populations but also are found in various indigenous societies, such as the Melpa, a horticultural village people in the Mount Hagan area of Papua New Guinea. The Melpa humoral system includes three primar y elements: (1) blood, which represents kinship ties through women and is associated with red ocher and red-colored foods; (2) grease, which takes the form of breast milk, semen, fat, the nurturant component of vegetables, and the fertility capacity of the soil and which may become depleted during pregnancy; and (3) a complex hot/cool/cold distinc- tion (Strathern and Stewart 1999). In the last case, blood that becomes “hot” may dr y up as a result of sorcer y, whereas high altitudes are believed by the Melpa to be too “cold” to maintain life on a permanent basis. Blood and grease exist in finite supply and may become scarce, resulting in illness. The Melpa view blood and grease as analogues to wealth as they know it, including pigs, shells, and money. Another indigenous people, the Tuareg, a pastoral group that makes its home in the Sahara and Sahel of West and North Africa, also subscribe to\ a com- plex distinction between “hot” and “cold”: TABLE 3.1 Theories of Disease or Illness Theories of Natural Causation Infection Stress Organic deterioration Accident Overt human aggression Theories of Supernatural Causation Theories of mystical causation Fate Ominous sensations Contagion Mystical retribution Theories of Animistic Causation Soul loss Spirit aggression Theories of Magical Causation Sorcery Witchcraft Understanding Health, Illness, and Disease 73 Conditions of “hot/cold” and associated afflictions are sometimes \ literal, some- times non-literal or metaphorical in connotations, for example, “hot”\ illnesses (tuksi) are believed to be caused by too much heat, from “hot” f\ oods (dates, to- matoes), sunlight, or moon-beams (these latter may cause illness from \ direct [con- tact or exposure], as in sun-stroke, or, alternately, by sitting on warm mats or from their reflections inside doorways). Tuksi may also result from anger and other strong sentiments. . . . “Cold” illnesses (tessmat) are the counterpart of “hot” \ ill- nesses. These include urinary tract problems and STDS. (Rasmussen 2004:\ 1005) Humanizing Biomedicine Health anthropologists examine conceptions of health, illness, and disea\ se across societies. As part of this endeavor, various health anthropologists have\ sought to humanize biomedical care by recording patients’ illness narratives (\ their stories of their illness experiences, concerns, and reactions) so as to assist \ physicians to better understand their patients, their patients’ views of illness, a\ nd their patients’ experiences of being sick. In his important book The Illness Narratives, Kleinman (1988), for example, a prominent physician-anthropologist, sought to persuade his colleagues within the corridors of biomedicine to listen closely to \ what their patients have to say, how they say it, and what they are trying to communicate.

Patients, Kleinman stressed, order their experience of illness in light \ of what is significant to them and others. These personal narratives give coheren\ ce to the encounter with suffering. But patients do not tell completely private st\ ories; rather they draw on plot lines and metaphors from their cultural heritag\ e to cre- ate accounts that are meaningful to them and for telling their stories t\ o others.

Illness narratives express what matters most in patient lived experience\ . As this focus on patient narrative reveals, health anthropology often has as its\ applied goal the explication of sufferer experience, especially among those who \ suffer in silence because their voice is discounted by more powerful social groups\ or strata.

Sufferer Experience Experience and Cultural Symbols When Jerry, a gay man in Ohio, learned he was infected with HIV, he was \ twen- ty-six years old. When he subsequently was interviewed by a health anthropol- ogist, he had been living with the infection for eleven years. He had re\ mained relatively healthy during this period (diseased but not ill) until jus\ t about a year before the interview. By then, he had developed severe pain in his legs \ and a gen- eral decline in stamina, eventually forcing him to stop working. Still, \ he empha- sized, “I’m a survivor, no matter what, y’know? I can make ends\ meet. I can get through anything. I guess maybe I get that from the streets, y’know? \ No matter what happens, you gotta keep going” (Bloom 2001:43). A very different health-related experience was told to another health an\ thro- pologist by a thirty-five-year-old woman who was losing hope of ever h\ aving a child: 74 Chapter 3 My chances are getting smaller and smaller. It’s like somebody has cancer and you say, “Well, you have a 20 percent chance that you will live”; and then go down to 10, and then to 5, and then you say, “You’re not going to live, let’s face it. You are going to die any day. Well, you just have to give up,”\ and I guess that’s where I am at now. . . . I really equate this with dying. (G. Becker 1994:396) As these two contrastive insider accounts of “sufferer experience”\ suggest, ten- sion between retaining hope, which is often expressed in a militant comm\ itment to fight against disease, and losing hope, which, in this instance, is\ expressed by way of a progressing disease metaphor, is a common motif in the accounts\ of people facing illness in Western culture. In other societies, illness experience is shaped by quite different cultural symbols and metaphors. In northeaster\ n Bra- zil, for example, the experience of having to suppress intense emotions,\ to avoid interpersonal conflict or social disruption, a behavioral event that i\ s thought to be a common cause of illness, is expressed through the metaphor of swall\ owing frogs (engolir sapos). Thus, speaking of her relationship with a domineering and abusive man, one of the women interviewed in a study of folk illness in \ Brazil stated, I always had to swallow frogs, you know, because I was totally dependent on him. . . . Even when I knew I was right and he was unjust, I had to swallow it, I\ had to obey. I had to apologize, I had to humble myself and submit, and even thank him for mistreating me, in fear of my life. (Rebhun 1994:367) Finally, a study with impoverished women in Nicaragua who reported suffe\ r- ing from “brainache” (dolor de cerebro), found that this symptom was reported in relation to women’s persistent worries about the impact of death, aba\ ndonment, and outmigration of adult children on personal and family well-being (Y\ arris 2011). Brainache embodies the vulnerability and distress women experience as they confront conditions of extreme hardship in their local social wo\ rlds.

In short, symptoms are culturally influenced although subjectively experienced and, as they are talked about, are “a necessary condition for us to articulate a relationship to the world and to others” (Biehl and Moran-Thomas 200\ 9:273). Cultural Emotions Culture is not just a cognitive system, something we use to experience, \ under- stand, and talk about the world; it is, in addition, an emotional system\ , some- thing that shapes our feelings and thus motivates our actions. By encaps\ ulating frightening or disruptive illness experiences in familiar and meaningful\ cultural frameworks, culture binds “the past and future together . . . and give the appear- ance of coherence or ‘return to the whole’” (G. Becker 1994:38\ 5). This is one of the ways in which pain, uncertainty, fear, and other physical and emotio\ nal chal- lenges of illness are culturally managed and, to greater or lesser degre\ e, tamed or even routed. Indeed, as health anthropology research on illicit-drug use\ rs living with HIV infection found, illness can even be experienced as salvation. \ As one of the participants in that study, a man who had lived with HIV disease for\ seven years, explained, Understanding Health, Illness, and Disease 75 The way I’m starting to look at it is that God got a plan to make you\ wake up and see things sometimes from this virus, to make you stop doing what yo\ u’re doing [e.g., using drugs], killing yourself. . . . I guess He wanted me to stop suf- fering and start looking inside myself and He presented this virus to me\ and said, “Hey, this is it! You want to keep doing this and die, or do you want\ to live and look at life on life’s terms?” And it worked. (Mosack et al. 2\ 005:595) Coming to view having HIV/AIDS as a “wake-up call” from God sug- gests the importance of cultural themes in individual sufferer experienc\ e. In this instance, the cultural leitmotifs mobilized by the sufferer are probably\ derived from Christian beliefs about individual agency and salvation through God\ ’s generosity. In this light, sufferer experience can be seen as a social p\ roduct, even though individuals from the same complex society may experience the same\ dis- ease in somewhat different ways. From the perspective of critical health anthro- pology, sufferer experience emerges from the action arena situated between socially constituted categories of meaning and social structures. This i\ ncludes finding culturally meaningful reasons why a person gets sick, such as \ “I failed to exercise enough,” “I was exposed to a virus when she sneezed on me\ ,” “I could not stay away from drugs” (figure 3.3), and the political-economi\ c forces that shape daily life and thereby place individuals in harm’s way, such as\ black lung disease among miners or malnutrition among children of the poor. In her highly acclaimed book Death without Weeping: The Violence of Every- day Life in Brazil, Nancy Scheper-Hughes presents a vivid and moving portrayal of human suffering in Bom Jesus, a dismally poor shantytown in northeast\ ern Brazil. She contends that the desperate and constant struggle for basic neces- sities in the community contributes to an indifference among mothers tow\ ard the weakest of their offspring. Scheper-Hughes recognizes that what moth\ ers of deceased children have in common is intricately related to the collapse \ of the sugar plantation economy, which left many people without even a subsistence in\ come.

While there has been local development, most of the residents of Bom Jes\ us have not benefited from the growth of agribusiness and the industriali\ zation sponsored by both transnational corporations and the Brazilian state, re\ sulting in inadequate diet and a high level of infant death. Maternal indifference \ to infant death, rather than the mournful response we expect of mothers who have l\ ost a small child—much like the laughter over tragic events reported among \ the shan- tytown dwellers elsewhere in Brazil (Goldstein 2003)—can be underst\ ood only in a social context. Goldstein (2003:39), in recounting the death of a\ poor man named Zeca, who died a prolonged, painful death and whose corpse initial\ ly was put in a refrigerator in a butcher shop while awaiting burial, notes, After Zeca died, the family had to pull itself together to dress him for\ the burial, but it was difficult to do so because his body was so stiff. The final, \ even more grotesque aspect of the story was that Zeca had a little “hard-on,”\ a detail that during each telling of the story [of his death] brought laughter to thos\ e who lis- tened and remembered one more time the details of this tragic story. For Soneca [his sister] and the others who witnessed his death, there was nothing l\ eft to do but laugh. The laughter was mad and absurd, similar to the conditions un\ der which they lived. 76 Chapter 3 Social Suffering Suffering, in other words, like cognitions and emotions, is far from a n\ arrow individual experience, and indeed much suffering in the world today is i\ ntimately connected to changes in the global capitalist economic system; these are\ played out and leave their effects on local physical and social settings and the people who inhabit them, including sparking rebellions against subjugation, som\ e of which inflict considerable suffering of their own. Health anthropologi\ sts use the term social suffering (Kleinman et al. 1997) to link individual experience of pain and distress to the wider social events and structural conditions that often are the ultimate sources of human misery. Social suffering, in short, refers to \ the imme- diate personal experience of broad human problems caused by the cruel ex\ ercise of political and economic power, such as forced abortion, coerced steril\ ization, terror, political rape (often used as a form of ethnic oppression), ex\ ploitation, and abject poverty, topics that have gained attention in health anthropology in recent years. Examination of painful memory is now a major anthropologic\ al topic of research. Painful memories include cultural trauma, which are “wounds in the collective memory that contribute to the construction of identity\ in dif- ferent social groups” (e.g., the trauma of slavery and the formation\ of African American identity or the trauma of the Holocaust and the construction of\ Jewish identity; Fassin and Rechtman 2009:25). In the analysis of the death of a Puerto Rican man in New York from the ravages of alcoholism (M. Singer et al. 1992), FIGURE 3.3 Drug user preparing drugs for injection. Photo by Robert Booth. Understanding Health, Illness, and Disease 77 for example, anthropology researchers sought to show the lines of connec\ tion between individual distress and disease and the colonial transformation of life and society on the island of Puerto Rico following the U.S. takeover in 1898\ . This included the subsequent dispossession of thousands of Puerto Rican farme\ rs of their land as a result of federal taxation and the thirst of giant U.S. \ agricultural companies for choice farmlands on the island. This landgrab resulted in \ the migration of thousands of Puerto Ricans to the U.S. mainland, where they\ had citizenship imposed on them during World War I so that they could be dra\ fted.

After migration, the hopes of Puerto Ricans for a better life often were\ dashed as they encountered intense discrimination in housing, jobs, education, and\ every- day activities in their new home. Subsequent massive layoffs from factor\ y jobs— one type of employment that, for a while, had been open to them—occur\ red when factory owners moved production south or out of the country in sear\ ch of ever-cheaper, more exploitable labor. Many migrants consequently suffered hopelessness, worthlessness, and a sense of failure, including the Puert\ o Rican man whose life became the subject of a health anthropology study. The scale and depth of social suffering in the world can at times overwh\ elm our ability to fully comprehend it: Knowledge of suffering cannot be conveyed in pure facts and figures, rep\ ortings that objectify the suffering of countless persons. The horror of sufferi\ ng is not only in its immensity but in the faces of the anonymous victims who have little voice, let alone rights, in history. (Chopp 2007:2) One objective of anthropology is to play a role in collecting the narratives of the survivors of the modern history of inequality and oppression as “test\ imony of suffering and yet surviving” (Chopp 2007:2).

Beyond Social Suffering Even under the bleakest of conditions there are lessons to learn about the nature of our species, insights that go beyond recognition of our capacity for \ rampant brutality. Anthropologists in recent years have studied the lived experi\ ence of war and political violence, especially among noncombatants who nonethele\ ss are among the most common victims of conflict and the unleashing of ar\ mies.

Examination of the political shaping of war knowledge, including management of events, images, and experiences, often serves to make war appear inev\ itable, acceptable, and even desirable. Enemies and those being characterized as\ future adversaries “are never seen for what they are (i.e., people like us,\ with families and friends, fears and desires)” (Rylko-Bauer and Singer 2011:226). In the pro- cess, the full extent and enduring nature of the human costs of war and \ political violence are often rendered invisible. In this vein, Carolyn Nordstrom (\ 1998) studied resistance to terror warfare and the crafting of identities base\ d on an embrace of such resistance among the people of Mozambique during the war\ of 1976 to 1992. She captures the startling brutality of that war in the fo\ llowing description by Adriaan van Dis: “Thousands of children have seen thei\ r parents die before their eyes, hundreds of children have been boiled in the pres\ ence of their parents. Heads of old people have been used as stools by the ba\ ndits, 78 Chapter 3 unwilling farmers are nailed to trees” (1998:108). Despite this inh\ umanity, Nordstrom’s (1998:113) field notes show that most of the conversa\ tions she had with Mozambicans during the war “in one way or another reflecte\ d their preoccupation with both healing the wounds of war—physical, emotional, and social—and defusing the cultures of violence that war had wrought.”\ These accounts and the heroic efforts they describe stand “as reminders tha\ t under the most extreme circumstances, the majority of people work to re-create a v\ iable society, not to demolish it” (Nordstrom 1998:113). Telling this often-forgotten story too is a mission of health anthropology.

Disability and Chronic Illness At the opening of this chapter, there is a quote from statesman and fi\ nancier Ber- nard Baruch indicating that he became interested in arthritis when he be\ came an arthritis patient. Similarly, the anthropologist Robert Murphy began his research on the issue of disability and being wheelchair-bound when cancer of the\ spine caused his legs to be paralyzed. On the basis of his experience and work\ in this area, he wrote a book (1987), discussed below, which has become an imp\ ortant piece in the disability and chronic disease literatures.

The Patient in the Body Murphy focuses his book on the insider’s experience: what it is like \ to be unable to walk, what it is like to be dependent on a wheelchair, and how this k\ ind of loss is far more than a painful physical transition. In addition to the \ loss of the use of his legs, Murphy realized that he had lost an essential part of h\ is sense of self. Despite strong social support from loved ones, he felt alone and i\ solated, a diminution of everything he used to be. At times, Murphy reported, he \ had a strong wish to withdraw from the world, to crawl into a hole and disappear, and to angrily mourn his loss of self. Before he was paralyzed, Murphy realized that he really did not see dis- abled people; he, like others, had been practicing a kind of selective b\ lindness when in the presence of a disabled person. This radically changed when h\ e was the disabled one, as he became hypersensitive to the social position and\ social treatment of the disabled, including the common tension and awkwardness \ of personal interactions between the disabled and the able-bodied. Social s\ ituations of this sort often lack clear-cut cultural guidelines about how to act, \ leaving peo- ple quite uncomfortable or in open distress. Murphy realized that people\ were giving him a wide berth and avoiding directly looking at him. He had beg\ un to vanish socially. He also retreated from his own body; like many paralytics, he felt less and less attached to his own body, less that he was his body. He su\ ffered, in short, not just a disease of the body but a disease of selfhood and a\ disease of social relationships. As Murphy’s poignant account makes vividly clear, disability is far m\ ore than a physical problem; rather, examination of disability, an issue that has\ engaged a number of health anthropologists, raises important questions about the\ basis of selfhood as a culturally constructed yet often taken-for-granted attribute. Understanding Health, Illness, and Disease 79 Additionally, it raises difficult questions about the ways in which cu\ ltural expec- tations shape social interactions and social relationships while challenging con- ventional ideas about what being normal means.

The Cultural Construction of Disability An especially important figure in the anthropology of disability is Jo\ an Ablon.

In her various studies of disabled groups, Ablon (1992:10) has focused\ on “the daily insults which endanger their personal identity and self-image, the\ ir social life, their economic opportunities.” She became especially concerned \ with social exclusion associated with being disabled and how to overcome these barri\ ers, including both those internalized by disabled people and those imposed by the able-bodied. In her well-known research with dwarfs, for example, Ablon \ (1984) emphasized that the dwarf body is different but not disabled and that dw\ arfs experience themselves and their bodies as normal. In interactions with t\ he wider society, however, they are subject to discrimination and frequent messag\ es about abnormality. Increasingly in recent years, health anthropologists have s\ tudied a growing range of disabilities and chronic health problems, including bli\ ndness (Ainlay 1989), deafness (G. Becker 1980), post-polio syndrome (Sche\ er and Luborsky 1991), impairments of mobility (Luborsky 1995), and psychiat\ ric dis- ability (Duncan 2017). Regarding the last of these topics, increasingly anthropologists have be\ en putting ethnographic inquiry to productive use in assessing the strength\ s and weaknesses of existing treatment modalities for psychiatric patients. An\ import- ant contribution to this body of work is Neely Myers’s 2015 book Recovery’s Edge: An Ethnography of Mental Health Care and Moral Agency, an area of study influenced by Myers’s challenging experiences with her brothe\ r, who was diagnosed with schizophrenia at a young age. The book is based on a thre\ e-year ethnographic study of a U.S. mental health treatment organization that s\ he calls Horizons (pseudonym). This program uses a treatment model known \ as recovery-oriented care. This involves treatment designed to assist and s\ upport an individual suffering from a serious mental health condition to “retur\ n to the life one might have expected to lead if one had never become ill—or possib\ ly even a better life” (Myers 2015:4). Invited by the directors of Horizons\ to study its approach to implementing patient-centered, recovery care, Myers’s goa\ l was to understand how the organization defined recovery, what this approach r\ equired of staff and care recipients, and the nature of facilitators and hindran\ ces of the recovery process. As used at Horizons, and elsewhere in the contemporary U.S. mental healt\ h treatment and support circuit, the recovery model asks “people to raise . . . out of [their] situation by becoming rational, autonomous, hard-working adul\ ts” (Myers 2015:19). In other words, the model prioritizes workforce reentry over the building of meaningful personal relationships, or, as Myers phr\ ases it, “work in place of wellness” (Myers 2015:52). Recovery is conceptualized within the program as a kind of existential journey that leads an individual to\ steady employment. On the one hand, this journey reflects American cultural images about the hero’s transformative journey of self-discovery and persona\ l growth, 80 Chapter 3 as expressed in successful movies like Harry Potter and the Philosopher’s Stone, the Star Wars series, The Matrix, Spider-Man, The Lion King, and the Lord of the Rings trilogy. On the other hand, the goal of the Horizon recovery j\ ourney aligns with American cultural values about taking active personal respon\ sibility for one’s life, maintaining a record of accomplishment, and gaining economic success. In Myers’s view, it is only once care receivers are employed\ that they prove themselves worthy of social recognition and reintegration with soc\ iety.

Myers refers to this as achieving “moral agency” in the eyes of pr\ ogram staff.

Recognition of having a right to moral agency, Myers contends, is only g\ ranted to care recipients after they evidence that they are rational, autonomou\ s, and productive, hardworking people. Stemming from the fact that the emphasis\ is on gaining outside employment rather than on building supportive relatio\ nships outside of the mental health-care system, care recipients find they must travel their journeys alone. Based on her experience with people diagnosed with\ seri- ous mental health conditions such as schizophrenia, Myers argues that estab- lishing dependable intimate relationships should be the first goal of \ treatment, not something delayed until after they are able to work, if people are t\ o succeed in their recovery journeys. Also, she is critical of psychiatric treatme\ nt programs that heavily medicate their patients because it dulls their experience a\ nd blocks the spiritual, emotional, and psychological work that is critical to the\ recovery process. In a related study, an intimate examination in Japan of the residents of\ a treatment community for people primarily suffering with schizophrenia, a\ health anthropologist lived for eight months with patient residents gaining the\ ir trust and getting to know about their lives and experiences (Nakamura 2013).\ As a result, through the presentation of detailed stories of patients’ liv\ es, it became possible to see beneath the usual stereotypes of people who historically\ have been stigmatized by Japanese psychiatry and society, and hidden at home \ or warehoused in impersonal, sterile institutions. Treatment, which includes full patient involvement in decision making, involves a limited use of psychi\ atric med- ications because they are seen as dampening patients’ emotional lives\ and social experiences. Emphasis is on self-reliance, social skills training, social support, and helping patients to manage the disturbing inner voices they hear. Pa\ tient hallucinations (referred to as Gencho-sans, “honorable voices”) are externalized from patients and modeled by dolls or by members of the therapeutic grou\ p.

The treatment approach is based on the idea that sufferers do not recove\ r from schizophrenia; rather they learn to live with it, similar to the conception of alco- holism promoted by Alcoholics Anonymous. The study also addressed social factors in the emergence of mental health problems through the telling o\ f patient stories, such as a young man who prior to hospitalization had been worki\ ng in the Japanese motor industry. When he saw that shoddy work was being pass\ ed off as acceptable, he openly complained. In response, his supervisors subjec\ ted him to disturbing “reeducation” sessions that provoked the onset of hi\ s symptoms. In their work at the Philadelphia Geriatric Center, health anthropologis\ ts and colleagues (Scheer and Luborsky 1991) found that the decisions pat\ ients make about disability-related issues are infused with broader concerns a\ bout their identity and the fulfillment of personal and cultural expectatio\ ns. People Understanding Health, Illness, and Disease 81 who survived polio, for example, often learned from their health-care pr\ oviders that they should forget about having had a bout with polio, put the past\ behind them, and move on with their lives. This attitude reflected a wider cu\ ltural orien- tation during the era that polio was prevalent in the United States in t\ he 1950s.

For polio survivors who suffered polio-related disabilities later in lif\ e, the early polio-recovery cultural expectations they learned and embraced came back\ to haunt them as they encountered a new wave of functional losses many year\ s after their initial bout with the disease. It became clear to them that in hea\ lth the past may not always be left behind easily.

Trauma and PTSD Posttraumatic Stress Disorder (PTSD) has been a consequence, no doubt,\ of every war in history as well as all other violence and traumatizing events (e.g., earthquakes). Yet it was not until 1980 that the American Psychiatric A\ ssociation accepted PTSD as a legitimate diagnosis. The change was not fully welcom\ ed at first but met with controversy. Emphasized in the new diagnostic category was exposure to an external catastrophic trauma. In fact, PTSD is unique amo\ ng psychiatric diagnoses because of the need for there to be an etiological\ agent, the traumatic stressor. What was not realized when it was first introduced as a health condition is just how common PTSD is among both veterans and nonv\ et- erans. Also realized over time have been the range of symptoms of this p\ ainful condition, including negative cognitions, flashbacks, and mood states such as grief and despair as well as disruptive behavioral expressions such as o\ utbursts of anger, violence, impulsiveness, recklessness, hyper-vigilance, and self-\ destructive actions including abusive drinking and other illicit and prescription dr\ ug abuse.

Comparatively high rates of domestic violence among PTSD sufferers creat\ e the potential for “secondhand PTSD” among their traumatized children. In their approach to the study of PTSD, health anthropologists have emphasized the interview-based stories of sufferers, including their per\ ceptions of traumatizing events and their lived experience of the way their sympt\ oms have impacted their lives and social relationships. In a thorough accoun\ t of such stories told by combat veterans presented by Finley (2011), for e\ xample, we hear about the disturbing things witnessed by men and women deployed \ as soldiers in Iraq and Afghanistan. After they return to the states, often\ with little time to adjust to the transition between two very different experiential\ worlds, they report struggling to cope with confusing internal conflicts, inte\ nse grief, and jarring images. Finley stresses that not everyone who has fought in \ these wars suffers from PTSD and not to the same degree. How returning soldier\ s are treated and how PTSD is constructed by friends, family members, doctors, and other caregivers is an important component in the development or sev\ erity of the condition. In Haiti, the frequent experience of trauma is mediate\ d by the cultural concept of ensekirite (Creole for insecurity), which labels the collective experience of the costs of living at the crossroads of multiple threats \ produced by political instability, economic subordination, environmental precarit\ y, and the social strains of poverty (James 2016). A health anthropology lesson is that “Culture matters in PTSD, from resources that foster social and emotional support to interpretations of\ symptoms 82 Chapter 3 and how to make sense of trauma” (Collura and Lende 2012:135). A se\ cond lesson is that there is a need for a shift in the cultural dialogue from\ portraying PTSD as a chronic condition to recognizing that it need not be a lifelong illness.

Stigmatization Another and related topic of concern to health anthropologists is the pr\ ocess of health-related social stigmatization and the creation of what have been \ called socially “discredited selves” in which disease sufferers are blame\ d for their health problems. People with AIDS, for example, often have been accused of bein\ g responsible for their illness through immoral or illegal behaviors. What\ health anthropologists have found is that the experience of illness is far more\ than the exposure to physical symptoms. Fear of discrimination and stigmatization\ may prevent people from seeking health care. Fear of being diagnosed with a \ stigma- tizing disease is a primary factor in why Mexican laborers in California\ waited an average of eight and a half months before going to see a doctor for symp\ toms that turned out to be tuberculosis (Rubel and Garro 1992). Similarly, \ a study of breast cancer beliefs among Latina women in California found that about \ one- third of women who had immigrated from Mexico (but only about 10 percen\ t of those from El Salvador) believed that God gives people breast cancer\ because they lived a “bad” life, such as using illegal drugs (Chavez et a\ l.1999). Nota- bly, various studies have shown that Latinas have comparatively lower ra\ tes of self-screening or mammogram screening for breast cancer and as a result \ tend to be diagnosed at a later and more life-threatening stage of disease devel\ opment. A major contribution of health anthropology to the study of stigma has b\ een in the examination of its local social construction cross-culturally and\ over time.

As part of this work, researchers have examined the interface between lo\ cal cul- tural beliefs and practices and stigmatization for a variety of diseases\ . Addition- ally, they have challenged approaches that limit the analysis of stigma \ to narrow cognitive explanations without regard to larger structural forces, such as the exer- cise of power, the existence of social conflicts, and the use of struc\ tural violence. Additionally, by seeking to know sufferers directly, by striving to unde\ rstand their experience and point of view, and by bridging the barriers that di\ vide the well from the sick, the able-bodied from the disabled, and credible from\ discred- ited selfhoods, health anthropologists are able to use this otherwise un\ obtainable information in developing needed recommendations or programs designed to\ minimize the many social harms attached to physical illness, including t\ he dam- age done by stigmatization. In the case of the study of beliefs about br\ east cancer among Latinas, researchers used their findings to design a culturally \ appropriate intervention aimed at improving Latinas’ knowledge about and attitude\ s toward breast cancer as a means of increasing their use of breast self-examinat\ ion and mammography. In developing their program, these applied researchers “felt that it was imperative to incorporate the Latinas’ beliefs into the interv\ ention rather than dismissing them as silly or folkloric” (Chavez et  al. 1999:133). Outcomes with a sample of eighty-eight Latina women, in which fifty-one were as\ signed to the culturally appropriate intervention and thirty-seven to a control gr\ oup, found that the culturally based intervention was associated with greater incre\ ases in Understanding Health, Illness, and Disease 83 Stigma as a Social Driver of Obesity In recent decades, a global biologi- cal trend has been of the spread of overweight and obesity. Scientific evi- dence points to the effects of interre- lated structural factors including poverty, import-dominated food systems, chang- ing work patterns, the development of more sedentary life patterns, and the nature of the built environment to explain why so many people around the world are becoming obese. Despite the widespread nature of this trend, and the existence of local deviations from the norm, the dom- inant cultural model in both biomedicine and public health around the world and beyond these in the media and in popular discourse emphasizes individual respon- sibility and personal failure for becoming overweight (Brewis and Wutich 2015).

The core social message stigmatizes sig- nificant weight gain, which is portrayed as irresponsible, shows a lack of willpower, reflects laziness, and indicates a lack of self-respect. In short, fat is stigmatized as bad. These negative conceptions shape national and local policy and public health strategies, while undergirding the bil- lion-dollar weight-loss industry. Paradoxically, fat-stigma, rather than contributing to individual weight loss, undermines such efforts. People who experience weight discrimination are more likely to remain obese; “weight stigma begets weight gain” (Tomiyama 2014:8).

This is because the feeling of being “stig- matized and being explicitly aware of exclusions or mistreatments because of one’s ‘fatness’ predicts greater stress, fewer health-enhancing behaviors, and worsened health outcomes” (Brewis et al.

2017:258). In short, stigma is a social driver of obesity and, in fact, many of the health problems commonly attributed to being overweight are products of dis- crimination and stress resulting from the stigma. In everyday social life as they move about the built environment, people with high body weight encounter punishing architectures that block them from fitting in socially. These “fat stigmatizing envi- ronmental cues,” include too-small chairs, seat belts on airplanes that do not fit, narrow booth spaces in restaurants, and doors on low-slung cars (Brewis et  al.

2017:259). Although interpersonal inter - action (from staring or unwanted com- ments) are an important source of stigma- tization, the reminder of not fitting in, not fully part of society, is often built into the environment showing that “space, archi- tecture, clothing, and so on can also ren- der bodies pathological through system- atic exclusion” (Brewis et al. 2017:272).

knowledge about breast cancer and a significant lowering of stigmatizi\ ng beliefs about the disease compared to the control group.

Human Rights and Health The issue of suffering—and medical anthropological approaches to it—\ raises an important issue of urgent concern within contemporary anthropology, name\ ly, 84 Chapter 3 the discipline’s approach to human rights, including its stance towar\ d the notion of health as a human right. Since just after World War II, anthropology \ has struggled with this issue. This chapter in the history of the discipline\ opened with the “Statement on Human Rights” written by Melville Herskovits and\ thereafter adopted by the American Anthropological Association’s Executive Board (Amer- ican Anthropological Association 1947) as a reflection of the discipl\ ine’s initial perspective on this issue of global concern. The statement was drafted a\ s part of an international effort led by the United Nations to craft what would ev\ entually be called the Universal Declaration of Human Rights. The latter was inte\ nded to serve, in the grisly shadow of Nazi atrocities, as a collective affirm\ ation of global respect for human dignity and inalienable liberties. Herskovits, as an i\ nterna- tionally known anthropologist, was asked to bring cross-cultural anthrop\ olog- ical insight to the task of establishing an agreed-on bedrock of univers\ al moral imperatives concerning human rights and justice. Instead, reflecting a\ n important theme within the discipline, he rebuffed the idea that anthropology coul\ d con- tribute to this effort on three grounds: (1) the conception of rights \ and morality varies considerably cross-culturally; (2) as a science of culture, ant\ hropology does not make normative judgments about particular cultural practices, an app\ roach the discipline deems ethnocentric; and (3) in use, a universal declara\ tion can be used to justify sanctions against a society acting within the boundaries of its own culturally constructed moral system. While this approach was formally adopted by the American Anthropological\ Association, it never won universal agreement even among American anthro\ - pologists. Anthropologists long have been active in various social justi\ ce and human rights movements, including the fight against McCarthyism, the c\ ivil rights movement, the debunking of racism, the environmental movement, th\ e women’s movement, and the struggle to gain acceptance of health as a \ human right (di Leonardo 1998, Rylko-Bauer et al. 2006). These efforts ultimately chal- lenged the finality of Herskovits’s stance while, for the most part\ , recognizing the importance of being alert to his cautions. The foundation of this ch\ allenge is that (rigorous scientific) anthropology can make important contributions to lessening human suffering and that moral detachment in the face of suffe\ ring is not neutral; rather, it helps sustain suffering in the world. Silence, a\ s they say, can speak louder than words. In recent years, the moral compass has swung away from Herskovits’s p\ osi- tion to the point that at least some anthropologists now believe that in\ a world of exploitation and suffering, “only anthropological knowledge that i\ s politically instrumental is worth pursuing” (Goodale 2006:2). More broadly, at \ the turn of the twenty-first century, the American Anthropological Association (1999), in accepting that anthropology in use involves the application of scient\ ific skills and knowledge to the solution of immediate human problems, adopted its D\ ec- laration on Anthropology and Human Rights, which unambiguously rejected \ Herskovits’s position. According to this document, Anthropology as a profession is committed to the promotion and protectio\ n of the right of people and peoples everywhere to the full realization of th\ eir human- ity, which is to say their capacity for culture. When any culture or soc\ iety denies Understanding Health, Illness, and Disease 85 or permits the denial of such opportunity to any of its own members or o\ thers, the American Anthropological Association has an ethical responsibility t\ o protest and oppose such deprivation. This statement well reflects a broadly held view within contemporary a\ pplied health anthropology that it is possible to “create knowledge that is \ at once empir- ically grounded, theoretically valuable, and contributes to the ongoing struggle for greater justice” (Speed 2006:75). The issue of social suffering stemming from structural inequalities or h\ uman conflict and the problem of hindered and unequal access to quality hea\ lth care are natural entry points for health anthropology into the issue of human\ rights.

Today, health and human rights activists are waging a struggle to gain g\ lobal acceptance of health/health care as a human right. Health anthropologist\ s have a wealth of data corroborating the suffering associated with lack of hea\ lth and health care internationally. In the view of many people within the disci\ pline, health anthropologists have a moral responsibility to use their knowledg\ e to promote health as a human right in order to reduce suffering in the worl\ d and improve access to and availability of quality health care for everyone. Some health anthropologists promote the study of human rights as one of many idioms of social justice mobilization and call for the field to p\ ay attention to the power and limits that human rights discourse has in any given cir\ cum- stance. From this perspective, health anthropologists should not simply rally behind health as a right. Rather, the right to health should be treated as an object of ethnographic exploration allowing anthropologists to assess ho\ w it is called on, debated, negotiated, and actively resisted in specific cont\ exts (Willen 2011). Among the infamous “human wrongs” for which the twentieth \ century will forever be marked is that of genocide/ethnocide. The link that some have described between globalism and genocide raises it as a critical human r\ ights issue for the twenty-first century. In response to such calamity, health ant\ hropologists are in a position to contribute to the establishment of universal health\ care, safe and sustainable living environments, freedom from poverty, access to ade\ quate diets and clean water, and protection from physical and structural viole\ nce as inalienable human rights with significant health implications. As Paul\ Farmer (2004:245–46) asserts, Utopian ideals are the bedrock of human rights. By arguing that we must \ set standards high, we must also argue for redistribution of some of the wor\ ld’s vast wealth. . . . Claims that we live in a world of limited resources fail to mention that these resources happen to be less limited now than ever before in human history. . . . [I]t is time to take health rights as seriously as other human rights, and . . . stand side by the side of those who suffer most from an increasingly harsh “new world order.” Illness Narratives Personal accounts of illness experience, like the “swallowing the fro\ g” example cited previously, are called illness narratives, and they have become an\ important subject of research in health anthropology. Telling stories about life i\ s a central 86 Chapter 3 human social activity around the world, with good storytellers being soc\ ially rewarded. Narrative has been defined as “a discourse featuring huma\ n adven- tures and sufferings connecting motives, acts, and consequences in causa\ l chains” (Mattingly 1998:275). As contrasted with other kinds of talking, a nar\ rative is a story about a specific event or a set of linked events in which the ac\ tors perform specific behaviors with socially meaningful outcomes. Narratives need \ not be full, elaborate tales with a moral, and they may be embedded in the course of other kinds of talk. In the case of illness narratives, expressing feelings an\ d recalling actions around a particular illness form the core elements.

The Social Uses of Narration Illness narratives have been interpreted by health anthropologists in se\ veral dif- ferent ways, including as a common way “by which people organize, dis\ play and work through experiences” (Rubinstein 1995:259). A primary way we “\ make sense of . . . experience is by casting it in narrative form” (Gee 1985:11). A n\ ar- rative often “affixes blame and assigns responsibility” (Mattin\ gly 1998:286), thereby setting moral boundaries around what is acceptable and what is u\ nac- ceptable while pointing to a course of action. In this, narratives may b\ e future oriented. Hearing a narrative augments a listener’s “fund of cultu\ ral knowledge” with which to confront future life challenges, including key cultural in\ formation about symptoms of various illnesses, their course and causes, and benefi\ cial responses (Price 1987:315). At the rise of the AIDS epidemic in Haiti,\ for example, narratives about individual cases helped Haitians come to grips\ with understanding this new threat by “providing the matrix within which n\ ascent representations were anchored” (Farmer 1994:801). Moreover, narratives often point to the future to imagined ends our lives are intended to fulfill\ (B. Good 1994). In addition, narratives are a cultural mechanism people use to a\ cquire or assert particular social identities and self-understandings (Cain 1991)\ .

Analyzing Narrative People who are suffering from significant illness tend to tell three k\ inds of stories (Frank 1995). The first of these are “restitution narratives,”\ a term that refers to linear stories that begin with a serious illness and end with the restoration of health, often through medical intervention. Such stories affirm to listeners t\ hat illness need not be an end point: people recover. Such stories often are told to peop\ le when they are ill to help them maintain hope and good spirits. The second typ\ e of illness narrative are called “chaos stories.” These are filled with unce\ rtainty, confusion, and a sense of powerlessness in the face of overwhelming forces. For example, in a study of drug users living with HIV, one of the participants stated, I can [tell] . . . my body is getting smaller, like something sucking me at like the neck, and everything is getting stringier and weaker, and I know this. A\ nd every- thing’s showing, like my ribs and stuff, and the flab outside my face\ is gonna sink and I know this. (Mosack et al. 2005:597) Understanding Health, Illness, and Disease 87 The final narrative type is called the “quest narrative.” Rather\ than recover, the person advances to a higher or superior state of being. While the person\ may not always return to physical health, spiritually or morally illness del\ ivers them to an elevated plane. New religions, in fact, often are started by indiv\ iduals who have been sick but during their illness undergo a transformation, believ\ e they have communicated with the supernatural, and never resume their prior id\ entity but instead become missionaries for their new faith. Typical is Handsome\ Lake, a Seneca Indian and alcoholic who lived at the turn of the eighteenth ce\ ntury.

Lying in bed, deathly ill, Handsome Lake had a series of three transform\ ative visions involving the receipt of messages from the Creator. These events\ led to the development of the Code of Handsome Lake, a religious doctrine for h\ ealing the Seneca people of the social and individual devastation wrought by co\ lonial contact. From an applied standpoint, M. Singer and coworkers (2001) use the nar\ - ratives of drug users to gain lessons for culturally appropriate AIDS pr\ evention.

They argue that analysis of the corpus of narratives they collected from\ street drug users holds three important lessons for confronting the AIDS epidem\ ic in this highly vulnerable group. First, it is evident in the stories that a\ cts of gen- erosity and caring on the street are unexpected and that when they occur\ they are seen as especially welcome surprises. As a result, these applied res\ earchers maintain, programs that work with drug users should go out of their way \ to treat them with dignity, respect, and authentic concern. Second, drug us\ er sto- ries emphasize the survival value of always remaining wary of betrayal. \ Avoiding actions that can be construed (rightly or wrongly) as duplicity should\ be avoided to the degree possible. Finally, the narratives stress the skills and ab\ ilities of drug users, attributes that fly in the face of the usual way they are depic\ ted in society, namely, as “losers,” unproductive burdens, and threats to social t\ ranquility and safety. Reversing the social message of denigration and worthlessness, b\ y treating drug users as socially resourceful, knowledgeable, and goal-oriented ind\ ividuals, offers promise of engaging them in health programs. One of the ways that narratives currently are used in health interventio\ n is through what is called “graphic medicine.” This term was coined\ by a phy- sician and cartoonist who defined it as “the role that comics can p\ lay in the study and delivery of health-care” (Williams 2012). The originator \ of the term subsequently launched a graphic medicine website to draw attention to th\ e growing number of illness graphic narratives that were available. Graphi\ c narra- tives, or graphic novels, are book-length stories in the style of comics\ . Graphic narratives of health experiences include stories about mental illness, sexually transmitted diseases, obsessive compulsive disorders, epilepsy, and canc\ er.

As the second-leading cause of death in the world, cancer has been the t\ opic of a number of graphic narratives, including graphic memoirs and biograp\ hical comics. Anthropological analysis of cancer graphic narratives suggests t\ hat they tend to legitimize biomedicine and biotechnology, upon which cancer pati\ ents come to be dependent for life, while diminishing issues of social inequa\ lity (McMullin 2016). 88 Chapter 3 Embodied Health Experience Over the course of the past three decades or so, anthropologists and oth\ er schol- ars have turned their attention to historical and cross-cultural studies of concep- tions of the human body and of embodied human experience (i.e., experiencing the world from within the confines of our bodies). The anthropology o\ f the body, however, harkens back to French anthropologist Marcel Mauss’s a\ ssertion that bodily sensations are mediated by culture and Maurice Merleau-Ponty\ ’s concept of “embodiment,” which draws attention to how the body int\ ernalizes cultural meanings. Today, the body is a central focus of work being done\ under the banner of health anthropology, including a focus on embodied experie\ nce, such as the folk illnesses in which people “feel” invasive forces \ or beings in their body, representations of the body, and the actual cultural shaping of th\ e body through decoration or tattoo or as a result of unintentional factors suc\ h as cul- turally constituted or structurally imposed diets. Although the body is \ generally viewed as a biological entity, particularly within biomedical circles, i\ t also in large part is a sociocultural construction. Further, the body functions as a v\ ehicle for learning about our environment. In the view of many societies, perhaps p\ articu- larly indigenous ones or peasant communities, it is an open system that \ links the self, society, nature, and spiritual world.

Why Bodies?

In part, interest in the body is driven by recognition of its increasing fragmentation and commodification within the contexts of biomedicine and global economics.

With reference to the former, some health anthropologists argue that in \ diagnos- ing and treating sickness, biomedicine focuses on human biology, more than on human pathophysiology (Hahn and Kleinman 1983). Hospital physicians often refer to patients as body parts based on the primary site of the patient\ ’s disease (e.g., the liver in room 327 or the kidney in room 783). Biomedicine t\ ends to radically separate the body from the nonbody, although critiques of biom\ edicine in recent decades have prompted some physicians to turn to a biopsychosocial orientation and/or to embrace complementary and alternative therapies as\ well as to improve their bedside manner by more actively touching patients. Various social factors also have contributed to a growing interest in th\ e body in the social sciences. Modern art, particularly as exemplified in the\ classic work of Picasso with his Cubist paintings depicting rectangular-shaped body p\ arts, stimulated an awareness of the way the body has become fragmented in mod\ ern societies. The growth of a consumer culture with its emphasis on the cul\ t of the body exemplified by cosmetics, fashion, and advertisements (as well a\ s tattooing and piercing) also played an important role in enhanced focus on the bo\ dy. At the same time, the feminist movement, particularly with respect to its emphasis on reproduction and sexual violence and the harmful effects of the objectifi\ cation and manipulation of the female body, technological innovations associated with reproduction, and the replacement of bodily organs, as well as cosmetic \ surgeries like face-lifts and breast implants, all contributed increased focus on \ the body as the site of immediate human experience. Last but not least, diseases \ that can Understanding Health, Illness, and Disease 89 leave marks on the body (e.g., skin lesions and discoloration, pocks, r\ ashes, severe loss of weight), have contributed to a scholarly interest in the body.

Body Theory Michel Foucault, Pierre Bourdieu, and Bryan Turner are perhaps the three\ most important social theorists in recent times whose work has contributed to\ an enhanced appreciation of the role of the body in societal processes and \ the role of society in bodily attitudes and practices. Foucault argued that the tran\ sition from premodern to modern society entailed a shift from sovereign power to disciplinary power. Whereas in premodern society power, at least in the European cont\ ext, resided in the body of the monarch, in modern society it resides in the \ bodies of diverse populations. Disciplinary power, which refers to the ways in \ which bodies are regulated, trained, maintained, and understood, is exerted pa\ rticularly in schools, prisons, hospitals, and asylums. According to Foucault, disciplinary power is expressed by various instruments. One of these is an elaborate \ system of hierarchical observation and tracking designed in the form of a Panop\ ticon in which officials can observe all “prisoners,” normalizing judgmen\ ts made particu- larly by teachers, physicians, social workers, psychologists, and health\ promoters and allowing a detailed comparison of the actions or attributes of indiv\ iduals.

An instrument of particular interest to the health anthropologist is the\ physical examination or “clinical gaze” of biomedicine. Within the context \ of the clinic, the biomedical examination facilitates the categorization of diseases in\ terms of various symptoms, such as the patient’s expressed experience of pain,\ and signs, such as pulse rate. Knowledge of the body translates into power over the\ body, or what Foucault called biopower, on the part of not only the physician but also the state he or she serves. For Foucault, biomedical knowledge is one of the several discourses by which modern populations are disciplined and controlled. Pierre Bourdieu argued that the body as manifested through its shape, speech, and gait translates into physical capital, which, along with eco\ nomic capital (e.g., money, wealth, and property), cultural capital (e.g., \ education and knowledge of arts and high culture), and symbolic capital (e.g., prese\ ntation of self), serves to influence an individual’s position in the social \ hierarchy of a partic- ular society. In other words, people experience the bodies of others and, in turn, may attempt to have their own bodies experienced by others in terms of v\ arious qualities, such as (1) being trim and fit as signs of having high self-esteem; (2) speaking “properly,” such as use of what is termed “the King’\ s English”; and (3) having good upright posture as an expression of confidence that \ conveys meaning about the character and social standing of the person being obse\ rved.

This kind of body language, in fact, can speak louder than words in esta\ blishing a person’s rights and entitlements. Bryan Turner (2008) argues that modern communities have been moving toward a new “somatic society”—a social system in which the bod\ y constitutes a central field of political and cultural activity as exemplified by a\ n emphasis on safe sex, sex education, free condoms, clean needles, controlling pollution, \ healthy eating, proper amounts of exercise, and other physical concerns expresse\ d by 90 Chapter 3 various social movements, particularly those focusing on feminist, abort\ ion, fer- tility, and environmental issues. Turner’s work focuses on the vulnerability of the body, and has addressed issues of aging, disease, and injury. These prov\ ide met- aphors for conceptualizing the dominant institutions of society that increasingly are thought of as vulnerable to disease (e.g., computer viruses), at risk because of the aging of the infrastructural technology on which they depend and thr\ eatened with injury from cyber-attacks. Ultimately, even dead bodies matter, culturally. This is seen, for examp\ le, in the social response to the emergence of body donor decisions in which in\ divid- uals voluntarily donate their entire body, after death, to anatomical sc\ ience for education and research. One impact of this kind of decision is that the people who feel close to the deceased are denied access to a mourning space suc\ h as a cemetery. This has led to the construction of donor monuments that provi\ de the bereaved a symbolic resting place for their lost loved ones. Dead bo\ dies also matter to the students who learn anatomy through the dissection of corps\ es.

Anthropological research indicates that “students find themselves s\ hifting back and forth between considering the corpses either as objects of study or a human beings who had real relationships” (S. Bolt 2012:619). To avoid this ambigu- ity, medical students try—although not completely successfully—to distance themselves from the bodies they work on by sticking to scientific term\ inologies, avoiding the bodies unnecessarily, focusing their attention on abnormali\ ties, and employing humor to lighten the otherwise somber mood of the dissecting r\ oom.

Bodies in the Age of Immunology In a pioneering book, Napier (2003) examines one of the important ways\ in which culture shapes the sufferer conception and experience of illness i\ n bodily terms. In his thesis (2003:3), “immunology as a cultural paradigm .\  . . has found its way into our lives, and the power of that way of seeing may be evidenced in various personal and professional domains, including—because they focus on ‘well-being and its absence’—the medical sciences.” Immunolo\ gy is a biomed- ical field concerned with the structures, systems, and processes within the body that protect it from pathogens and infection. Napier argues that immunol\ ogy offers a paradigm (i.e., a particular way of understanding, ordering, a\ nd experi- encing “reality”) that shapes how patients, doctors, and many oth\ ers in and far beyond the health/healing domain think about their bodies but also about the world as well. Central to this paradigm is the notion that the world exi\ sts as two opposed categories. The first of these is self (at the individual level: one’s iden- tity, body, internal organs, and at the social level: us, members of one\ ’s family or social group, friends). The second is not-self (at the individual level: things that may intrude into my body and cause illness, such as infections, toxins, bad influences, drugs, and at the social level: them, outsiders, foreigner\ s, enemies, terrorists). In what has been called the immunological age, the era in \ which we now live, “the self/not-self opposition is fundamental. In this confrontation, selves become immune—safe—if and only if the dangerous not-self—bacteria, viruses, tumors, or radically different others—is either destroyed or\ neutralized” (Stoller 2008:30). As a result, to take the example of cancer, doctors\ and patients Understanding Health, Illness, and Disease 91 (depicted as allies in the language of modern biomedicine) fight an \ internal war on disease (which is portrayed as an invading not-self entity), comple\ te with reconnaissance missions (X-rays and other technological weapons for internal imagining), incendiary bombing (radiation), search and destroy missio\ ns (sur- gical removal of tumors), and use of biochemical warfare (chemotherapy\ ), all of which are expected to produce a certain amount of damage from friendly fi\ re (i.e., killing cells that are part of self, not other) but, if the bat\ tle is fought well, lead to victory with the patient becoming a cancer survivor. As a result\ of expo- sure to this culturally constructed metaphoric world, “it is not uncommon for .  .  . people .  .  . to think of malignant cells as alien invaders that are completely separate from .  .  . [their] bodies” (Stoller 2008:34). Notably, however, it is in fact the case that malignant cells are self; they are something the pati\ ent’s own body produces (although possibly upon exposure to pollutants or other t\ oxins).

But cancer sufferers tend to deny this fact because of the pervasiveness\ of the cul- tural division of self and not-self, a theme that extends far beyond the\ health of the individual body to debates about the health of the social body (e.g., debates about immigration). Despite the prominence of the immunological paradigm, it is good to remember that biology tends not to be ordered by simple self/other relat\ ion- ships. In autoimmune diseases, it is the body’s own immune cells that\ attack other healthy body cells. Similarly, while it is technically a foreign b\ ody (with antigens different from those of the mother), the mother’s immune sy\ stem usu- ally does not attack a developing fetus. Moreover, even differences we t\ ake for granted, like the existence of biological distinct male and female bodie\ s within our species, is subject to rethinking. The frequency of deviation from standardly defined male or female bodies may be as high as 2 percent of live birt\ hs (Blackless et al. 2000), although this is a disputed statistic.

Cyborg Bodies The boundaries between bodies and machines have become increasingly blur\ red, as anyone knows who has watched people engaged in nonstop video gaming, \ internet chatting, texting, cell phone calling, use of social media site\ s, or listening to music through a headset. This is particularly exemplified in the co\ ntemporary incarnation of cyborgs, mythical creatures that were half human and half\ animal or machine. Modern-day cyborgs include “test-tube babies” (assist\ ed concep- tion), people with organ transplants, people using artificial body pa\ rts (prosthetic limbs), as well as those who have undergone plastic surgery. Moreover, \ various social processes, including sports, dance, yoga, military training, cons\ truction work, body building, and computer work, as well as social class, ethnici\ ty, nation- ality, and culturally defined gender shape bodies. Within the context \ of late capi- talism, the commodified body functions as a site of production, a sour\ ce of labor power, a “baby machine,” an object of sexual pleasure in the form \ of prostitu- tion, a supplier of transplanted body parts, a source of beautificatio\ n in the form of cosmetic surgery, and a source of profit. These are important healt\ h-related developments addressed in chapter 8. 92 Chapter 3 Mindful Bodies Within health anthropology, Nancy Scheper-Hughes, Margaret Lock, and Emily Martin in particular have made major contributions to the scholarly stud\ y of the body. Lock and Scheper-Hughes point out that in addition to its array of\ ana- tomical features, such as a set of interrelated biological systems, the \ human body is mindful in that it is the site of individual experience, social expre\ ssion, and the inscription of structural relations. On this basis, these researcher\ s delineate what they refer to as the three bodies of concern, a delineation that ha\ s impacted thinking within the discipline for several decades. The first of these is the “individual body,” which comprises the\ “lived expe- rience of the body-self” (Lock and Scheper-Hughes 1996:45). While t\ he notion of the individual body, conceived of as a separate and unique entity, dr\ iven by intention and will, is quite compatible with Western ideas about individ\ ualism, this is not always the case. The Gahuku-Gama of Papua New Guinea histori\ cally conflated individual and social identity (Read 1955:276). In other w\ ords, they did not conceive of themselves as fully distinct individuals; rather, th\ eir identities were embedded in their roles and responsibilities as members of a social\ group.

In such cases, the good of the group overwhelms personal interest or int\ ention, and thoughts of oneself separate from the group are unsettling. Traditionally, a version of this way of conceptualizing the self has been found in Chines\ e cul- ture. A core aspect of Chinese culture is its emphasis on relationalism (guānxì xué), which involves viewing human relatedness, rather than separateness, \ as the essence of human existence. The Chinese “self” traditionally was n\ ot an inde- pendent entity; one’s life could be meaningful only through coexisten\ ce and interaction with others. The Chinese term guānxì refers to both a relationship type and to the idea of closeness. Under the influence of globalism, the individualization of self has be\ come more common everywhere. The world of the Gahuku-Gama, for example, has changed dramatically, with urban encroachment, involvement in a global e\ con- omy, and significant cultural change (Read 1986). In the contemporar\ y world, there are whole new dynamics that must be considered in understanding th\ e body at the individual level. One such area of growing interest among he\ alth anthropologists is the topic of organ transplantation. This operation, w\ hich often is seen as a pinnacle of biomedical skill and achievement, a “medical\ miracle,” is of keen interest to health anthropologists in part because it involves t\ he crossing of traditional cultural and physical boundaries (e.g., the notion that \ body and self are intertwined and integral to each other) and the corporal mixin\ g of “self” and “other” in ways that challenge cultural notions of personhood,\ personal property, the distinction between life and death, and what Joralemon has\ called “the intuitively unambiguous connection we feel to our bodies” (1995:347).

Undergoing such an operation, as a recipient, can be a personally transf\ orma- tive experience. Afterward, the individual’s sense of self and self-w\ orth often is changed (Sharp 1995). At the same time, cases have been ethnographical\ ly doc- umented of family members of a deceased organ donor seeking out the reci\ pients of their relative’s transplanted organs, people they had come to thin\ k of as new kinsmen, a phenomenon that has begun to occur, as well, among the childr\ en Understanding Health, Illness, and Disease 93 of diverse mothers with a common sperm donor biological father. On the o\ ther side of the transplant operation, in the arena of organ procurement, esp\ ecially in low-resource countries, the poor often are subject to exploitation an\ d may be pressed to literally sell their body parts to survive, while large numbe\ rs of citizens in wealthy countries refuse to donate organs even at death. In an anthro\ pologi- cal study in India, for example, researchers found that kidney donors we\ re paid approximately $1,500 and that most used the money “to pay off debts i\ ncurred for wedding dowries and other types of loans,” among other expenses (\ Marshall and Daar 2000:213). In addition, at times, criminal elements in the procurement business have kidnapped individuals to steal transplantable organs such \ as kidneys for sale on the organ market. Indeed, a worldwide system that has been c\ alled “organ tourism” has emerged in which individuals from wealthier co\ untries gain life by acquiring organs from the people of poor countries, a practice that some have interpreted as a veiled form of structural violence. In a grisly turn of events in the world of organ transplant, over the pa\ st several decades more than fifteen thousand families in the United States have brought suit against funeral home employees, crematorium operators, and morgue workers claiming that body parts, from knees to skin, were harves\ ted without consent from their deceased relatives and sold for profit. Police have found that entire bodies have been sold for tens of thousands of dollars\ , with elbows and hands fetching $850 each (Amour 2006). While the sale \ of body parts is illegal in the United States, the sheer demand has motivat\ ed the creation of a black market in transplantable organs and other body p\ arts.

From an anthropological perspective, this turn of events represents a fu\ rther commoditization of human life and experience, namely, the transformation of objects, nature, emotions, relationships, indeed, ultimately everything,\ into salable products in the capitalist marketplace. One health anthropologist who has long studied living organ donation and\ is the founder of Organs Watch, an organization focused on exposing the egregious moral abuses of international organ trafficking, has likened it to “\ sacrificial vio- lence” (Scheper-Hughes 2007). This organization asserts that the po\ or often must sell a kidney to a transplant harvesting company (known by their critics as “kid- ney hunters”) in order to raise the money to flee as refugees from\ conflict or the damaging environmental effects of climate change. But having two kidneys\ does not make one of them a spare organ, and the long-term medical, psycholog\ ical, and social consequences of selling a kidney are not widely reported. These include chronic pain, depression, self-loathing, distorted body image, a sense o\ f bodily emptiness, anger, isolation, and even suicide (Scheper-Hughes 2016). The “social body,” the second component of Lock and Scheper-Hughes\ ’s tripartite model, refers to representations of the body as a “natural\ symbol with which to think about nature, society, and culture” (Lock and Scheper\ -Hughes 1996:45). Indeed, one often hears expressions such as a “healthy soc\ iety” or a “sick society” to refer to either societies with a high degree of \ social cohesion or societies with a high degree of fragmentation, as if societies could get\ illnesses the way bodies do. To a large degree, Lock and Scheper-Hughes note, talk abo\ ut the body and sexuality tends to be talk about the nature of society and about socially acceptable standards of moral behavior. This assertion reflects a broa\ der point 94 Chapter 3 made in anthropology that “the human body is always treated as an image of society [and therefore] . . . there can be no natural way of considering the body that does not involve at the same time a social dimension” (Douglas \ 1973:98).

This point is well captured in a statement made by Richard Carmona, form\ er surgeon general of the United States, about the problem of obesity in th\ e United States. He stated, “Obesity is the terror within. Unless we do someth\ ing about it, the magnitude of the dilemma will dwarf 9-11 or any other terrorist \ attempt” (quoted in J. Harris 2006). Terrorism, by intent, is targeted at socie\ ties, not indi- viduals per se. In likening obesity, a problem of individual bodies, to \ terrorism, a social threat, the surgeon general affirmed our tendency to use the \ body as a symbol of society and vice versa, a pattern found around the world. Finally, there is the “body politic,” a concept that draws from th\ e work of Fou- cault and that refers to the “regulation, surveillance, and control o\ f bodies (individ- ual and collective) in reproduction and sexuality, work, leisure, and s\ ickness” (Lock and Scheper-Hughes 1996:45). With respect to biomedicine, a medicalized\ body is a “manifestation of potent, never settled, partially disguised politi\ cal contests about how aging and rebellious bodies should be managed” (Lock and Scheper\ -Hughes 1996:68). We are reminded of Rudolf Virchow’s often-quoted historic \ statement that “politics is medicine on a grand scale.” In looking at the bo\ dy from the stand- point of political relations in society, health is a reflection of the\ unequal hierarchy of relations in society, and health anthropologists are mindful of the w\ ays in which inequality, exploitation, and structural violence are recorded “under\ the skin” in the social distribution of health and in the patterning of biology acros\ s social classes and other lines of social difference. A nutrient-deficient diet, for e\ xample, is more likely to be found among the poor than among the wealthy in a society, a\ nd this difference is reflected in the actual formation of the teeth and bones\ of societal members. Society, quite literally, is inscribed on our bodies and one ne\ ed go no further than a tattoo or piercing parlor to see contemporary expressions\ of this.

Thus modern tattooing has been interpreted as “a symptom of a culture\ that has commodified the body” (Fisher 2002:91). Gender is another important arena of bodily social control. As contraste\ d with societies characterized by limitations on food availability, in which a plump figure often is seen as a sign of beauty, in modern America a slender, androgy- nous body has become a valued female physique. Expectations of thinness are reinforced heavily by the advertisement industry. Studies of magazine co\ ntent have found high numbers of ads and articles about food, including recipe\ s and accounts of the newest chic dishes. At the same time, magazines frequent\ ly give voice to social angst about obesity while exhibiting images of perfectly\ sculpted bodies attained through the use of exercise machines, workout routines, and an endless array of miracle diets advertised nonstop in media commercials. The cul- tural celebration of thinness and stigmatization of obesity are critical\ factors in the emergence of epidemic levels of food-related disorders, such as anor\ exia and bulimia, in U.S. society. Although eating pathologies have been a peculi\ arly Western and middle-class phenomenon, in recent years they also have begu\ n appearing in non-Western countries, as well as across socioeconomic classes, ethnicities, age groups (including among the elderly), and even gender\ s. Recent Understanding Health, Illness, and Disease 95 analysis has focused on the role of globalization and the diffusion of A\ merican or other Western images of the “ideal” body type as critical elements\ in the chang- ing international face of eating disorders.

Engendered Bodies Much of the work on the anthropology of the body focuses on gender issue\ s, including the cultural construction of gendered bodies, that is, bodies \ that are not just different biologically (e.g., sexual organs, roles in reproduc\ tion, capac- ity to nurse infants) but are constructed as different within cultural \ frames and conceptions. In The Woman in the Body, for example, Martin (1989) asserts that the body in the United States is viewed through the cultural lens of a m\ achine metaphor that emerged during the industrial era. Biomedicine, she mainta\ ins, treats women’s reproduction of the social group by giving birth as a \ cultural form of factory production in which “uterus machines” produce babies with the phy- sician managing this process. It also regards menstruation as a failed p\ roduction process. Biomedicine also has treated the body as a passive object over \ which particularly women came to lose control, although the women’s movemen\ t even- tually challenged this trend. In another case, in contrast to the anorexic-like female body that has b\ ecome idealized in Western societies, Fijians, a Melanesian people in the Sout\ h Pacific, value a well-proportioned, robust body (A. Becker 1994). They believe \ that such a body indicates that a person is capable of arduous labor and that he o\ r she has been well nurtured. A third example comes from the Mediterranean area, where it has been observed that women “represent the code of honor of the family and the code of shame via the blood revenge for nonfamily member’s transgressions.\   .  .  .

The honor/shame dichotomy is evident in the highly guarded aspects of wo\ m- en’s virginity, chastity, marital virtue, and especially fertility”\ (Olujic 1998:34). As these examples indicate, cultures ensnare and diversely elaborate biolog- ical differences, with significant but different social and health imp\ lications for women and men.

Understanding Medicalization The term “medicalization,” mentioned in chapter 2, was introduced \ into anthro- pology from sociology and refers to the role of medicine in social contr\ ol. At the simplest level, medicalization means giving a bodily condition or a beha\ vior a medical label, defining the problem in medical terms, and using a me\ dical intervention to treat it. While many health anthropologists now use the \ term, medicalization was coined by the influential sociologist Irving Zola. \ He pointed out that when a problem, such as overeating, is medicalized, there tends\ to be a reduction in the degree to which the disorder is stigmatized because oth\ er causes besides individual moral failings are ascribed, be they the consequence \ of patho- gens or the effects of genetics. This process has been called the transf\ ormation from “badness to sickness” (Conrad and Schneider 1980). At the s\ ame time, as 96 Chapter 3 conditions are medicalized, there is an ever-growing expansion of the ju\ risdiction of medicine over arenas of social life and experience. In that medicine \ is now highly commodified, medicalization also involves the medical marketing\ of prof- it-making commodities to address body issues, such as menopause treatments, clinical weight-loss programs, sleep deprivation interventions, and smok\ ing ces- sation initiatives. Critics have warned about the ways physicians are ex\ panding their power over the public through what has been called “the medical\ ization of life” (Illich 1975). In recent times, there have emerged “demedi\ calization move- ments,” such as the largely successful struggle to have homosexuality\ removed from the list of medically recognized psychopathologies. Within health anthropology, an issue of concern is the ever-creeping bou\ nd- aries of problems defined as appropriate for medical intervention and \ hence med- ical social control. Lock (2003:117), with reference to the medical ma\ nagement of everyday life, notes: First, . . . emotions and sexuality become targets of medical technology, with the result that reproduction of populations and even of the species are \ medical- ized. Similarly, other activities, including breastfeeding, hygiene, exe\ rcise, de- portment, and numerous other aspects of daily life are medicalized—largely by means of public health initiatives and with the assistance of the popula\ r media.

With some issues, such as substance abuse, medicalization may be less repressive than the alternatives, such as criminalization. Ironically, i\ n the United States, during the very period that the National Institute on Drug Abuse\ , an arm of the National Institutes of Health, began declaring chemical addiction\ and dependence to be diseases of brain chemistry, involving a restructuring \ of neural pathways in response to exposure to drugs, the country continued to buil\ d many new prisons each year to house the large number of individuals arrested \ for the possession of these substances, including, increasingly, illicitly sold \ and used prescription drugs. Alcoholism and alcohol dependence, by contrast, have\ been much more fully medicalized, and street alcoholics, for example, are no \ longer arrested and incarcerated for public inebriation. At the same time, as Lock (2003:123) points out, with “moleculariza\ tion, geneticization, digitization, computerization, and globalization .  .  . the potential exists to make the body increasingly the site of control and modificat\ ion, much of it carried out, in the West at least, in the name of individual right\ s or desires.” Healer versus Sufferer Conception of Disease The Two Sides of Compliance As documented in many studies, patients do not always follow doctors’\ orders, a behavior that often is labeled “noncompliance” in biomedicine. But\ this finding is not peculiar to patients in biomedicine and has been documented for alte\ rnative medical systems as well. In fact, studies have shown that doctors themse\ lves often are out of compliance with existing standards of care. As Gawande (2002\ :236), a physician, comments, “Physician compliance with various evidence-ba\ sed Understanding Health, Illness, and Disease 97 guidelines ranges from over 80 percent of [cases] in some parts of the c\ ountry to less than 20 percent in others.” Supporting Gawande’s assertion\ , a twelve-city U.S. study of medical care found that patients received recommended care\ for their diagnosed health problem only 54.9 percent of the time, ranging fr\ om a high of 78.7 percent for senile cataract treatment to a low of 10.5 perc\ ent for the treatment of alcohol dependence, findings that led the researchers to \ conclude that the failures of clinical adherence pose significant threats to th\ e health of the American public (McGlynn et al. 2003). Other research shows that the way doc- tors handle the same diagnosis varies considerably; the likelihood, for \ example, that a patient with a gallbladder problem will be sent for surgical removal varies by 270 percent by city, and for a hip replacement the variance is 450 pe\ rcent (Wennberg 1999). Not only are physician decisions highly variable, but\ in a series of articles in the prestigious Journal of the American Medical Association, a physician who studies clinical decision making described them as often\ being arbitrary (Eddy 1990). While health anthropologists have not focused much of their attention on\ physician compliance with established medical procedures, they have been\ quite interested in patient behavior. In this, they have been quick to point out that an important component of illness behavior stems from the fact that patient\ s are not blank slates waiting to be inscribed by their healers; rather, they have\ beliefs and ideas of their own. Illness, especially one with familiar symptoms, does\ not elicit an empty response; rather, sufferers and their significant others, inc\ luding those in one’s social network who are thought to have greater experience in\ handling health problems (e.g., grandmothers), commonly engage in folk diagnosi\ s, and it is on the basis of such reflection that specific kinds of profess\ ional, folk, or popular treatment are sought. As one health anthropologist observed, “\ Health programs that fail to recognize and work with indigenous beliefs and practices also fail to reach their goals” (Scrimshaw 2001:53). A case in poin\ t is that of Tamil refugees living in Norway but originally from Sri Lanka, where the\ y were used to being treated in the Ayurvedic medical tradition. Suffering from\ diffuse aches and pains in their bodies, the Tamil seek therapy from the local b\ iomedi- cal health-care system. The experience, however, is often disappointing.\ As one patient complained to a health anthropologist, “The problem is that N\ orwegian doctors only see my body and organs. They don’t see my person. Very o\ ften doctors do nothing. We feel very uncertain” (Grønseth 2006:152).\ The problem in this instance is that Tamil think of their health problems in terms o\ f a humoral system of hot/cold balance. The failure of Norwegian physicians to addre\ ss the imbalance, Tamil patients feel, makes them appear unconcerned and useless.

Another patient stated, I don’t know how to explain. I only know that sometimes a sickness ma\ kes you too hot or too cold. So, you need to make food and use mixtures that wil\ l bring you back in balance. . . . Here, the doctor doesn’t want to know our prob- lems and give no advice and no pills. They can’t cure our difficultie\ s. (Grønseth 2006:153) 98 Chapter 3 Insider and Outsider Assessments of Health Status What do sufferers know, subjectively, about their health status, and how\ does sufferer knowledge compare to that of the healers who are treating them?\ Several studies on this topic have produced interesting results. In a study in D\ enmark, researchers (Geest et  al. 2004) asked 456 middle-aged individuals who subse- quently had a health screening performed by their general practitioners \ to rate their health status on a five-item scale ranging from “very poor”\ to “excellent.” In 68 percent of cases, doctors and their patients agreed about the pati\ ents’ health status. In a U.S. study of noninstitutionalized elderly individua\ ls, it was found that self-assessments of health were a better predictor of mortali\ ty than objective biomedical assessments (Idler et al.1990). Similarly, self-a\ ssessment has been shown to be a superior predictor of return to work among indivi\ duals suffering from chronic pain than objective clinical or radiological test\ results (Yelin et al. 1980), while, based on a study among cancer patients, re\ searchers concluded that self-assessment “is valid, reliable, and responsive to change as a predictor of survival of advanced cancer” (Shadbolt et  al. 2002:2514). These findings are striking because traditionally, biomedical physicians hav\ e tended to discount patient self-assessment as a source of information about patien\ t health.

One Word, Two Meanings Another aspect of the sufferer versus healer conception of disease invol\ ves the existence of various disease names that mean one thing to sufferers and \ another to healers. For example, health anthropologist McCombie has studied a ph\ e- nomenon she refers to as “folk flu.” In her study in the America\ n Southwest, she found that the word “flu” “does not mean the same thing t\ o the epidemi- ologist that it does to the public, who include illnesses with a number of clinical presentations” (McCombie 1999:31). Importantly, McCombie found that\ the discrepancy between the health-care system and lay sufferers in the mean\ ing of the term “flu” is more than a matter of semantics because people think they have the flu when, from a biomedical perspective, they are suffering from a\ different disease, including giardiasis, viral hepatitis, and salmonella infection\ . Similarly, in a study in Washington, DC, Merrill Singer and coworkers (1984) foun\ d that the folk illness “hypoglycemia” (low blood sugar) was fairly com\ mon, especially among middle-class women, who reported a range of symptoms. However, man\ y physicians would agree and would find that the majority of those who b\ elieve they are sufferers of this affliction do not meet diagnostic requireme\ nts for the disease. While some physicians have suggested that underlying emotional \ prob- lems are the real cause of widespread folk beliefs about hypoglycemia, t\ hose who believe themselves to suffer from the disease are critical of biomedicin\ e’s failure to understand this affliction and its victims. In this sense, hypoglyc\ emia functions as an idiom of distress among middle-class women who think that their li\ ved experience of suffering is not taken seriously by biomedicine. As these examples show, even when patients and healers use the same dis- ease labels, they may be, in effect, speaking different languages or, mo\ re pre- cisely, marshaling different bodies of information and different underst\ andings. Understanding Health, Illness, and Disease 99 The potential for provider-patient miscommunication in such cases is eno\ rmous.

By exploring diagnostic labels and their meanings to the parties involve\ d in a clinical encounter, health anthropologists are in a position to help min\ imize this problem.

Diseased but Not Ill Given the definitions that have been offered for illness (as subjecti\ ve experience) and disease (as objectively measured phenomena), it is possible to have a \ disease but not feel ill. This disjuncture is quite common with diseases such as hyperte\ nsion, which has been called “the silent killer”; the early stages of various c\ ancers; and infec- tious diseases such as HIV/AIDS that generally do not produce many sympt\ oms, although very early symptoms are often misinterpreted as the flu until\ sufferers have been infected for a number of years. In such cases, adherence to medical\ instructions is complicated by the fact that the patient feels fine and has diffi\ culty believing they are suffering from a life-threatening disease. Conversely, it is possibl\ e for sufferers to feel quite ill but be told by their physicians that nothing is wrong (e\ .g., folk hypogly- cemia) or that their problem is psychosomatic. In some cases, however, \ the real prob- lem is that disease exists but is unknown to biomedicine. Chronic fatigu\ e syndrome, for example, was producing misery among sufferers long before it was rec\ ognized as a bona fide disease by biomedicine. It was not until 1988 that the \ disease was recognized by the Centers for Disease Control and Prevention, although the term “myalgic encephalomyelitis” began appearing in the medical literat\ ure in 1938 and is still used today in some parts of the world, particularly in the Unit\ ed Kingdom, to label this disease. Even so, controversies about the disease, which was \ once derided as the “yuppie flu” and its sufferers mocked as “rich, whiny whi\ te women,” continued until 1994 when an international panel of researchers was convened and a\ clearer definition of the disease developed to assist clinicians in making a d\ iagnosis. Accepted signs of the disease, which afflicts about a million people in the Uni\ ted States, most of whom are neither rich nor white, include having a significant level of fatigue that has lasted for over six months and having four or more of the following \ motley array of symptoms: substantial impairment in short-term memory or concentratio\ n; sore throat; tender lymph nodes; muscle pain; multijoint pain without swelling or redness; headaches of a new type, pattern, or severity; unrefreshing sleep; and m\ alaise lasting more than twenty-four hours following exercise. Like the definition fo\ r AIDS, there is no clear-cut indicator but rather a set of factors occurring together\ that definitively signals the presence of the disease. Complex diagnostic criteria such as\ these often are the source of communication problems between patients and physicians.

Mismessaging Another type of miscommunication that can occur is exemplified by fi\ ndings in a study of HIV testing among drug users carried out by several health anth\ ropolo- gists and in collaboration with researchers from other disciplines. In t\ his project, the researchers offered oral HIV testing because it was far easier for p\ articipants and less risky for research staff in terms of accidental “sticks” with a syringe that 100 Chapter 3 had been used to draw blood from a participant who was HIV positive. In \ oral HIV testing, a small antibody collector that looks like a short-handled \ toothbrush is inserted for a short time between the inside cheek and gum of the par\ ticipant.

The collector does not capture the HIV virus (which does not tend to su\ rvive in the mouth) but rather draws out antibodies (if they are present) that the body produces to fight off infection. While HIV is not frequently transmitted orally (e.g., through kissing), it occurred to the researchers that being tes\ ted orally might convince participants that HIV could, in fact, be transmitted thro\ ugh oral contact. Subsequent interviews with individuals who had and had not been\ tested orally affirmed the researchers’ suspicion. Those who had been test\ ed orally were significantly more likely to believe that HIV could be transmitted thr\ ough kiss- ing, sharing a cup, or other types of oral contact (Clair et al. 2003). Why is this finding important? Does it matter if people think HIV can be transmitt\ ed in ways that are not in fact common routes of infection? If people believe that no matter what they do they are likely to get HIV, then they are less likely to fo\ llow any prevention strategy (e.g., using condoms). Consequently, it is critica\ l that false beliefs about transmission be understood and corrected to increase the l\ ikelihood of adopting effective behaviors for preventing disease. Here again, heal\ th anthro- pology, which generally sees understanding the insider’s point of vie\ w as a topic of concern, can make a contribution to community health.

Analyzing Health Discourse This discussion of communication in the health domain suggests the growi\ ng importance of discourse analysis in health anthropology. This type of st\ udy focuses on the communication (be it verbal or involving gestures, writt\ en texts, or electronic media) that takes place between people in the health doma\ in, such as clinical conversations between doctors or other healers and their pat\ ients.

In part, this work has focused on the ways health-care providers and pat\ ients construct shared cultural worlds through conversation or other communica\ tion.

Additionally, this kind of analysis has emphasized the ways that inequal\ ities in access to knowledge shape health-related communication and help to under\ gird medical authority (Briggs 2005). Similarly, a keen interest to health \ anthropolo- gists involved in medical discourse analysis is the social origin and st\ ructural func- tions of the messages exchanged in clinical encounters. Thus, medical di\ scourse may have as its effect “the creation and maintenance of the interests\ of certain hegemonic groups” (MacDonald 2002:464). Silences are also of importance.

Consider the implications in a biomedical encounter in Australia as a provider attempts to record a patient’s medical history and the patient happen\ s to be a member of an aboriginal community that culturally bans talking about one\ ’s past serious illnesses. Exploration of change is also essential, especially i\ n the kind of fast-paced globalizing world that we all now inhabit. Based on detailed \ analysis of dyadic clinical encounters between providers and patients and other forms of medical discourse, a body of recent studies traces interactions between \ discourse forms that circulate globally and local traditions of practice to assess\ patterns of change over time and place (Wilce 2009). Understanding Health, Illness, and Disease 101 Discussion Questions 1. What is health? What are the ways it has been defined? Why is it so hard to develop a widely shared definition? What does anthro- pology add to the definitional process?

2. Is death the great social equalizer or not? What are the implications of your answer for the human condition?

3. How and why do health an- thropologists differentiate ill- ness and disease? Is this a useful differentiation?

4. Why do beliefs across disease causation and approaches to cure var y across societies?

5. Why is it important to under - stand sufferer experience? How do health anthropologists study suf- ferer experience?

6. What have health anthropologists contributed to the study of disabil- ity and mental health (including PTSD) issues? Do you see these as important contributions?

7. How have health anthropologists’ views of human rights changed over time? Why did this happen?

8. What are illness narratives? Why do health anthropologists study them?

9. Why has the conceptualization of “the body” become so import- ant in health anthropology? What insights has studying the body provided? What is meant by the notion of the “mindful body”? 102 4 The causes of many diseases are a complex interplay of multiple factors,\ many of which are due to social injustice. —Barr y Levy and Victor Sidel (2006:11) Introduction and Overview H ealth and disease are unequally distributed across populations. Malaria,\ for example, is found in some places but not in others, while some segments of a population are much more likely to get tuberculosis than others. Mo\ reover, access to health care and treatment within health-care settings is not uniform; many studies of health care in the United States, for instance, show tha\ t African Americans get different—generally poorer—health care than white Am\ ericans.

These differences have been variously labeled health disparities or heal\ th inequal- ities. As will be seen in this chapter, these terms are not fully synony\ mous. Ad- dressing inequalities in health and health care has become an important \ arena of work in health anthropology research and application. In this chapter\ , we (1) define health disparity and health inequality; (2) examine the nature \ of disparities in health within the context of U.S. society; (3) review the debates about the causes of health disparities; (4) closely scrutinize three key issues \ in U.S. health disparities: asthma, access to health insurance, and the development of \ cultur- ally competent health care; (5) move from the United States to a cross\ -cultural examination of health disparities; (6) discuss methods and approaches \ in amelio- rating disparities and inequalities in health; (7) discuss the roles t\ hat health an- thropologists are playing in addressing health disparities; and (8) conclude with a discussion of the issue of the biological concept of “race” as a\ factor in health disparities. What Is Health Disparity?

It is noteworthy that at no period of time “in the history of the Uni\ ted States has the health status of minority populations—African Americans, Nati\ ve Amer- icans, and, more recently, Hispanics and several Asian subgroups—equa\ led or even approximated that of white Americans” (Geiger 2003:417). Even though important scientific and technical advances in biomedicine have occurr\ ed over the past several decades, for many people of color these have not contri\ buted to an equalization of health and well-being with other groups in society. I\ n other words, certain groups have not benefited fully or equitably from the g\ rowth of biomedical knowledge and medicine’s expanded capacity to heal. As not\ ed by Health Disparity, Health Inequality 4 CHAPTER 4 HEALTH DISPARITY, HEALTH INEQUALITY Health Disparity, Health Inequality 103 HEALTH DISPARITY, HEALTH INEQUALITY the Institute of Medicine (2012:16–17), “health disparities exis\ t from the cradle to the grave, . . . the data show elevated rates of mortality for African Americans and American Indians at all ages compared with those for whites. . . not only are mortality rates higher for racial and ethnic minorities, but these group\ s must also contend with earlier disease onset and a greater severity of disease.”\ The term “health disparities” refers to disproportionate or excess\ morbidity, mortality, and decreased life expectancy as well as unequal access to he\ alth care and other health-supportive resources (e.g., insurance or access to goo\ d nutri- tion) especially but not solely in disadvantaged groups in society or i\ n the world at large. This has emerged as a major public health issue worldwide. While the term health disparities references differences in health across groups, the term health inequalities points also to underlying structural causes in disease distribu- tion, namely, that social inequalities produce health inequalities. The \ term health inequality, in short, focuses on the role of unequal social relationships embedded in the economy, political system, educational system, medical system, an\ d else- where in society in creating worse health in some groups compared to oth\ ers.

Health Disparity in the United States Although the United States is the richest country in the world and the m\ ost technologically advanced, this has not translated into having the best h\ ealth or the greatest life expectancy for either men or women. Overall life expec\ tancy in the United States for the total population, however, masks significant\ differences by subgroups. For example, while the life expectancy on average is 76.3 \ years for white males, among African American males it is 67.8 years, almost e\ ight years less than white men. Among white females, the average life expecta\ ncy is 79.9 years, while for African American females it is 74.7 years, about five years less than white women. African Americans have been found to be at signifi\ cantly greater risk of death, including premature death, than whites, with most existing studies showing a 30 percent higher age-adjusted risk of mortality among\ Afri- can Americans. Higher prevalence of several diseases, including hypertension, HIV infection, ischemic heart disease, stroke, and cancer, accounts for \ the higher death rate of African Americans. Much of the difference in this burden of dis- ease—but not all of it—is explained by differences in the socioeco\ nomic status (SES) of African Americans compared to whites. In a meta-analysis of s\ everal national studies, it was found, for example, that African-Americans experience about 67,000 more deaths than they would have had their mortality rates been similar to whites. This translates into 2\ .2 million more YLL [annual years of life lost]. After adjusting for SES, these numbers drop to about 38,000 lives and 1.1 million YLL. Thus, roughly 29,000 of \ the lives lost and 1.1 million years lost annually may be attributable to di\ fferences in income and education between the groups. (Franks et al. 2006:2472) The additional burden of morbidity and mortality among African Americans\ after statistical adjustment for SES is believed to be a consequence of the he\ alth dam- age done by racism and discrimination throughout the lifecourse leading \ to the 104 Chapter 4 direct and indirect bodily effects of stress, including adverse chemical\ changes.

African Americans who perceive that they are being subjected to racism h\ ave been found to have higher blood pressure than those who do not (Krieger\ and Sidney 1996). Moreover, SES and being the object of racism have been fo\ und to interact, increasing the adverse health effects of each. As these dat\ a suggest, ethnicity, and how it is handled socially, appears to be an important fa\ ctor in health in the United States. In fact, researchers have found that there are considerable and conseque\ n- tial inequalities in the distribution of health, disease, and access to \ health care across populations, subgroups, and regions of the United States. While t\ he issue of health disparity has received a growing level of public health, polic\ y, media, researcher, and public attention in recent years, it remains a topic of \ considerable debate, especially with regard to the causes of disparity and its social\ solutions.

Studies have found multiple indicators of health disparity; for example,\ with reference to the impact of ethnicity on access to health care, the Insti\ tute of Medicine (2002) reported the following findings in a review of multi\ ple studies: •health-care providers appear to give less intensive care to African American patients compared to white patients.

•African Americans are significantly less likely than whites to receive a major therapeutic procedure.

•African Americans receive fewer health care ser vices than whites.

•Mexican Americans with myocardial infarction are 40 percent less likely than whites to receive thrombolytic therapy.

•African Americans are less likely to receive even low discretionar y care (e.g., for clinically urgent health problems like appendicitis and abdominal aortic aneur ysm).

•Latinos were found to be less likely than non-Latinos to undergo major medical procedures.

•African Americans with diabetes were found to be significantly more likely to undergo amputations and less likely to receive lower-limb arterial revas- cularization.

•Latinos with long-bone fractures are twice as likely as non-Latinos to re- ceive no medication for pain.

•Minority cancer patients are less likely to receive adequate analgesic medica- tion for pain.

In short, the care you receive in biomedicine is determined by many fact\ ors, including who you are in terms of the social construction of ethnicity. Gasping for Breath The various studies of the health-care system noted above—and many more that could be mentioned—affirm considerable inequity based on ethnicity \ and income in the United States. Similarly, there are major inequalities in the dis\ tribution of diseases. Consider, for example, asthma, a disease that has become more \ prevalent in the twenty-first century. More than twenty-five million people in\ the United States suffer from asthma, about a third of whom are children under eigh\ teen years Health Disparity, Health Inequality 105 of age. Asthma has been identified as one of the most common chronic i\ llnesses of childhood in the nation; however, this breath-robbing disease is not equally distributed among children of different ethnicities or socioeconomic sta\ tuses.

National surveys report an overall lifetime asthma prevalence of 12.2 pe\ rcent for children (under eighteen years of age), although there are dramatic di\ fferences across ethnic groups and subgroups (Dey et  al. 2004). Rates of asthma are espe- cially high among African Americans and some Latino groups. Compared wit\ h white children, African American and Puerto Rican children have 1.6 and \ 2.4 times higher asthma prevalence, respectively. Lower socioeconomic status\ also is linked to increased asthma morbidity, and minority children are dispropo\ rtionately impacted by lower socioeconomic status (Carroll 2013). Houston, Texas, the fourth-largest city in the United States and the hom\ e of large numbers of Latinos and African Americans, for example, is one o\ f the fifteen most polluted cities in the country and exhibits high rates of\ respiratory ailments, including asthma, in large part because of air pollution from \ motor vehicles and petrochemical plants (Harper 2004). In the Houston metrop\ olitan area, people of color and working-class people in general tend to live i\ n closer proximity to freeways and petrochemical plants than do affluent whites\ . As a result, different communities in Houston report different rates of asthm\ a diag- nosis. Only 12 percent of white households with children ages five to \ seventeen have a house member with an asthma diagnosis. This compares with 24 perc\ ent of African American families in the city. African American families repo\ rt being much more likely to have gone to the emergency room or urgent care for an asthma-related incident than other families (Binkovitz 2017). While distressing, reported rates of asthma among Puerto Ricans probably underestimate the actual prevalence of the disease in this population be\ cause many symptomatic children are not diagnosed. Research by Whitman and coworkers (2004) in Chicago, for example, found that when cases of “\ possible asthma” based on a report of patient symptoms rather than actual medi\ cal diag- nosis were added to cases of physician-diagnosed asthma, the prevalence \ level for Puerto Rican children jumped to an alarming 34 percent. This higher rate\ sug- gests the potential overall significance of asthma among Puerto Ricans\ . In a study of asthma among children in East Harlem, New York, Puerto Rican children\ with asthma were found to be more likely to miss school because of asthma tha\ n chil- dren of other ethnic groups from the same neighborhoods (Findley et \ al. 2003).

This study also found that low-income Latino families that have young ch\ ildren with asthma lack the necessary information, training in asthma managemen\ t, and medical resources for good asthma control. The problem, however, is \ not simply one of the health-care system failing to adequately prepare Latin\ o parents in asthma management. Notably, the Childhood Asthma Severity Study (Ort\ ega et  al. 2002), which surveyed over a thousand children and their families, \ found that Latino and African American children were given fewer beta2-agonist\ s, which is a standard medicine in asthma management, and, further, that La\ tino children received fewer inhaled steroids than white children. One hazard of asthma for children is stigma, a factor that is associated\ with limiting needed asthma medication in public or in front of peers to avoi\ d the embarrassment and exclusion of being stereotyped as a sick child. While \ asthma 106 Chapter 4 is often portrayed in the media as a minor or manageable disease, in the\ life experience of children it can be terrifying. Anthropological content ana\ lysis of Hollywood movies, including those viewed by children, indicates that \ they have systematically stigmatized asthma and its sufferers. Interviews with children with asthma about representative scenes from a sample of child-oriented \ movies showed that they felt those with asthma were portrayed as “wimpy,”\ “a geek,” “a scaredy cat,” “freaked out” or “handicapped.” The c\ hildren objected to these portrayals as unfair and said they make them feel uneasy. Based on viewi\ ng such movies, the children expressed worry about what might be in store for th\ em as asthma sufferers during their lives (Clark 2012).

Causes of Health Disparity: Lifestyle versus Social Inequality The public debate over health disparities in the United States encompass\ es many different factors, but of central importance is a heated discussion of l\ ifestyle ver- sus social structural causation of health disparities.

Living Right The lifestyle view asserts that differences in health are a consequence \ of eating right, exercising, avoiding smoking, not using illicit drugs, drinking m\ oderately, learning to overcome stress, getting proper rest, and securing and adher\ ing to good medical care—that is, taking personal responsibility for your\ health.

It emphasizes individual-level decision making and behavior as the prima\ ry factor in wellness and poor health. This perspective flows from very core Ame\ rican val- ues concerning individual hard work and achievement and a tendency to be\ lieve that we are personally responsible for our own life situation, social st\ anding, and success or failure. Exemplary, in the book Real Age: Are You as Young as You Can Be? the author, a physician (Roizen 2001), provided a formula for people to ca\ lculate how many months of life they were losing because of their own behaviors (e.g., eating fatty foods or not flossing) based on the questionable assumpt\ ion that individuals are the primary determinant of their own longevity. On the b\ asis of the book, which sold millions of copies, the author founded RealAge, whi\ ch administers a test to establish a respondent’s lifestyle-related heal\ th status.

The company was subsequently sold for more than $60 million and findin\ gs from its popular online test (found at https://www.sharecare.com/group/reala\ ge) are used by pharmaceutical companies to target specific marketing mess\ ages for their drug products to test takers, which is contrary to the whole lifestyle per- spective (Clifford 2009).

Structural Explanation By contrast with the lifestyle perspective, the social structural view h\ olds that health disparities are more than the consequences of individual decision\ s and Health Disparity, Health Inequality 107 actions; they are the products of social inequality in many spheres of l\ ife, from opportunities in education and housing to treatment in the criminal justice sys- tem and access to health care. From this perspective, the key issue is n\ ot health disparity per se but health inequity and social injustice. From this und\ erstanding, health inequalities are unnecessary, avoidable, and unfair and they refl\ ect the ability of dominant groups to control needed resources in society.

As Krieger (2005:15) observes, Social inequality kills. It deprives individuals and communities of a he\ althy start in life, increases their burden of disability and disease, and brings ea\ rly death.

Poverty and discrimination, inadequate medical care, and violation of human rights all act as powerful social determinants of who lives and who dies\ , at what age, and with what degree of suffering.

Health adversities due to structural factors are often lifelong despite \ improved socioeconomic conditions. As the organization Voices for Childr\ en (Canny et al. 2002:29) notes with reference to women’s health, Women from lower income conditions as children [are] 58 per cent more li\ kely to show high insulin resistance than those who lived under higher income\ con- ditions as children. Women living in better social and economic circumstances as adults still had a 29 per cent greater chance of being insulin resistant\ if they grew up in low-income families. Women who grew up poor [also are] more likely to Social Status Inequality and Health In an interesting study of the effects of inequality on health, researchers studied the Tsimane, a forager-horticultural group living along the banks of the Maniqui River in lowland Amazonian Bolivia (von Rueden et  al. 2014). While it is a comparatively egalitarian society, the researchers did find degrees of status inequality among Tsimane men; higher-status men have more influence in group decision making.

These same men are called on by the group to represent the community in its dealings with outsiders. The researchers measured status by asking men to evalu- ate one another in terms of their influence in community affairs. The men also were asked to provide urine samples. Analysis of these two datasets showed that men with less political influence had higher levels of the stress hormone cortisol. Chronically elevated cortisol can impair cardiovascular and immune function. Accordingly, the less influential men had a higher risk of respi- ratory infection, a common cause of sick- ness and death among the Tsimane. The researchers concluded that higher-status men experienced a greater sense of con- trol and greater social support, factors known to have positive impacts on health.

If even in a small-scale, largely egalitarian society, status impacts health, how much more so does it affect health in societies structured by unequal social class, gender, or other social divisions? 108 Chapter 4 . . . have higher levels of bad cholesterol and obesity than those who lived\ under better socioeconomic circumstances as children. These relationships rema\ in . . .

after taking into account adult social and economic conditions. Consequently, there is a need to study the expressions and interconnecti\ ons of health inequalities across the life span (Adler and Stewart 2010). While poverty appears to be a critical factor in health disparities, hou\ sehold income is not the only issue involved. While health disparities are strongly influ- enced by poverty, disparity is greatest among poor people who live in ar\ eas with a high percentage of poor people in the local population. Thus, poor peo\ ple in cities with smaller impoverished populations are at lower risk of dyi\ ng than those in cities with large impoverished populations. In other words, the\ density of poverty in an area appears to be a crucial determinant of the health \ status of the poor. Moreover, studies of differences by location among the poor show that th\ e sociophysical environment in which people live—that is, their experie\ nce of their surrounding community, including issues of danger, stress, comfort\ , and appeal—is also an important determinant of their health. Feelings of \ hopeless- ness and powerlessness in a community have been found to be good predict\ ors of health risk and health status. One direction of the study of health among the poor developed by anthropologists involves the investigation of huma\ n biological responses to impoverishment, or what has been called the biol\ ogy of poverty. Recalling the disparities in health care reported earlier, it is also ev\ ident that ethnic discrimination by health providers, whether conscious or unconsci\ ous and whether driven more by individual or institutional bias, is another \ import- ant structural cause of disparities in health. An analysis of existing r\ esearch led to the conclusion that the key factor is “institutional racism,”\ a systemic tendency to view ethnic minorities as less worthy patients, an ideology \ that is grounded in power imbalances between minorities and professional elit\ es in medicine (King 1996). In their contribution to the Institute of Medicine review of health disparities, anthropologist Mary-Jo DelVecchio Good and\ coworkers (2003) emphasized the importance of the “culture of medic\ ine,” including how medical students and residents are trained in the perpetua\ tion of institutional racism in medicine.

Biology of Poverty Poverty, quite literally, is inscribed on and in their bodies. One of th\ e conse- quences of the biology of poverty is that, to the degree that poverty-in\ duced bodily defects and diseases are increased in a population, the challenge\ for that population of overcoming conditions of poverty without outside resources\ is greater. As a result, “the very conditions that give rise to disparit\ ies are likely to persist and perpetuate a dialectical interaction of inequalities and hea\ lth” (Leath- erman and Jernigan 2015:176). Under these conditions, the goal for heal\ th anthropology is to demonstrate the links between structures of inequalit\ y, like social class, and local biologies in local contexts. Health Disparity, Health Inequality 109 Insuring Disease Health insurance coverage has become an important measure of access to h\ ealth care in the United States. Yet tens of millions of Americans, especially\ ethnic minorities, have never had access to insurance coverage. As Figueroa (2\ 004:i) aptly points out, Not having health insurance is deadly and costly. Even those with health\ insur- ance suffer from the insecurity of inadequate coverage and care. . . . [P]ropos- als to reform the nation’s health care system over the last several d\ ecades have succumbed to partisan politics and intensive lobbying campaigns by insur\ ance companies. Meanwhile, more than 44 million Americans are without health insurance.

Nationally, Latinos consistently have been found to be the group most li\ kely to lack health insurance across all age groups. Thus, Latino children ar\ e the most likely not to be covered by health insurance, with only 8.8 percent of n\ on-Latino white children lacking coverage in 1999 compared to 27.1 percent of Lati\ nos under eighteen years of age. In the same year, while 68.4 percent of non\ -Latino whites had employer-based health insurance, among Latinos this figure \ was only 43.4 percent. Despite some improvements, by 2003 only 79 percent of Lati\ no children had health insurance compared with 93 percent of white children\ and 86 percent of African American children (Holahan et al. 2003). Poverty, discrim- ination, parental lack of awareness of eligibility, language barriers, enrollment barriers, and fear (especially among undocumented immigrants) of reper\ cussions for using publicly funded insurance have been cited as factors to explain why so many Latino children do not have health insurance. Thus, for example, th\ e fact that in 2003 at least 30 percent of Latino children nationally lived in households with incomes below the federal poverty line, compared to 10 percent of w\ hite children, is likely an important factor in health insurance disparities \ faced by Latino youth (Interagency Forum on Child and Family Statistics 2005). Significantly, the Commonwealth Fund (Doty 2003) found that the numb\ er of uninsured Latinos has steadily gone up, doubling between 1990 and 200\ 2.

Lack of health insurance coverage is a significant determinant of both\ being able to be seen by a doctor when in need and having a primary care provider. \ More- over, the uninsured are much more likely to report that they are in poor\ or only fair health than are the insured. The Robert Wood Johnson Foundation (2005) reported that nationally 37.7 percent of uninsured Latinos are unable to\ see a physician at a time of need compared to about 10 percent of insured Lati\ nos.

Notably, among the insured, Latinos were the most likely to report inabi\ lity to be seen by a physician at a time of need. Additionally, uninsured Latino\ s are the ethnic group most likely to lack a personal physician, and, whether \ they are insured or not (but especially among the uninsured), Latinos are the m\ ost likely to report being in poor or only fair health. While 69.6 percent of unins\ ured Lati- nos nationally lack a personal physician (compared to 48.8 percent of u\ ninsured whites), almost one-fourth (24.5 percent) of insured Latinos also do \ not have a personal provider. Lacking personal physicians results in Latinos being \ the group most likely to rely on a community or public clinic for whatever health \ care they 110 Chapter 4 do receive (Doty 2003), with Spanish-speaking Latinos being almost fi\ ve times more likely than whites to get care in a community or public clinic. While 85 percent of whites receive care in a doctor’s office, this is true o\ f only 43 percent of Spanish-speaking Latinos. In short, many Latinos have little or no ch\ oice of where to go for medical care. Additionally, lack of health insurance coverage is a significant barri\ er to pre- ventive health care for Latinos in the United States. Thus, the Commonwe\ alth Fund (Doty 2003) found that comparatively low rates of insurance among\ Latinos limits their access both to routine preventive care, including v\ isits to the dentist, routine Pap tests among women, routine mammograms, routine prostate examinations, and help with management of diabetes, and to acute care at\ the same levels as the insured. As a result, the health of Latinos is furthe\ r compro- mised, with the resulting development of a number of significant chron\ ic health problems.

Culturally Competent Care Health disparity research suggests that ethnic minority groups such as A\ frican Americans, Latinos, and Native Americans suffer a triple burden in seeking health care: (1) they are significantly less likely to have health insurance than whites, so accessing care is a major challenge, and while adequate acute care is ha\ rd enough to come by, preventive care is all but impossible for those who are not \ insured; (2) in the health-care system, ethnic minority patients face individua\ l and insti- tutional discrimination at every level; and (3) culturally competent health care is in especially short supply. What is culturally competent health care? The Commonwealth Fund has defined it as the “ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery of c\ are to meet patients’ social, cultural, and linguistic needs” (Betancour\ t 2006:1).

In other words, from a health anthropology perspective, culturally compe\ tent care begins with the perspective of the patients, their culturally condi\ tioned understandings, attitudes, expectations, and feelings; more precisely, i\ ts start- ing point is patient experience and the often emotionally charged cultur\ al meanings attached to that experience (G. Becker 2004). At present, the\ re are major gaps between the health-care systems in place around the country a\ nd what would be considered culturally competent care in light of local eth\ nic diversity. Yet the need for health-care providers to meet the needs of e\ thnic minority patients is inescapable, as seen in the changing ethnic composi\ tion of the U.S. population. While individuals of white European and related heritage accounted for about 75 percent of the U.S. population at the time of the 1990 national census, current trends suggest that by 2030 whites will make up only 60 percent of the population. At that point, almost one in five norteamericanos will be Latino.

Since culturally competent health care is seen as being better health ca\ re, unless health-care systems adapt, the quality of care will continue to drop as the Amer- ican population diversifies. Health Disparity, Health Inequality 111 Recognizing these realities, there has been a push in health-care system\ s to (1) develop principles and standards of culturally competent care, (2\ ) implement curricula to train health-care providers in culturally competent care an\ d to eval- uate their adherence to learned approaches, (3) conduct research on the contri- bution of cultural competency to reducing disparities in health and health-care provision, (4) publish and disseminate reviews of best and promising c\ ulturally competent practices, (5) identify strategies to overcome linguistic an\ d cultural barriers, and (6) develop organizational structures to support cultura\ lly com- petent care. Reflecting these trends, the Office of Minority Health \ of the U.S.

Department of Health and Human Services has established national standar\ ds for health-care institutions such as hospitals and clinics to follow in \ responding to the medical needs of their culturally diverse clients. These standard\ s include the following components that indicate the nature of culturally appropri\ ate care:

(1) ensuring that patients receive effective, understandable, and resp\ ectful care that is provided in a manner compatible with their cultural health belie\ fs and practices and preferred language; (2) implementing strategies to recru\ it, retain, and promote a diverse staff and leadership that are representative of th\ e social and demographic characteristics of people living in the area served by t\ he health institution; and (3) ensuring that staff at all levels and across all \ disciplines receive ongoing education and training in culturally and linguistically appropri\ ate service delivery. Given their focus on the role of culture in health, illness, and healing, health anthropologists recognize the value and support the adoption of such sta\ ndards, although—often citing the costs they might entail—health-care prov\ iders are not always immediately receptive to changing their practices. Health anthrop\ ologists have found that it is important to demonstrate that culturally and lingu\ istically appropriate services, or what is called culturally competent health care\ , is, in fact, more effective in terms of producing better health outcomes, which is generally an accepted and valued goal among health-care providers. An alternative to the cultural competence approach, and a critique of it\ , is supported by physician and health anthropologist Helena Hansen and he\ r sociology colleague Jonathan Metzl. Rather than training in what often b\ ecomes simplistic understandings of culture in medical school, they propose tha\ t med- ical students receive education in what they call structural competency. In this approach, training is focused on the social determinants of health, an a\ rea that traditionally has not received adequate attention in biomedicine. For example, Hansen and Metzl argue that medical students should be trained in holdin\ g pro- viders (and insurance companies) responsible for the outcomes of their\ patients.

Clinical training, they maintain, should teach medical students the abil\ ity to “discern how a host of issues defined clinically as symptoms, attit\ udes, or diseases (e.g., depression, hypertension, obesity, smoking, medication ‘non-c\ ompliance,’ trauma, psychosis) also represent the downstream implications of a numb\ er of upstream decisions about such matters as health care and food delivery s\ ystems, zoning laws, urban and rural infrastructures, medicalization, or even ab\ out the very definitions of illness and health” (Metzl and Hansen 2014:128\ ). Training in structural competency includes five components: (1) recognizing the social 112 Chapter 4 structures that shape clinical interactions; (2) developing an extra-clinical lan- guage for clinicians to talk about structure; (3) rearticulating “c\ ultural” formu- lations in structural terms; (4) observing and imagining the nature of\ effective structural interventions; and (5) developing structural humility as physicians, which entails that physicians must be listeners and collaborators or are\ not the final authority on patient lives. As the importance of culturally competent care caught on in biomedicine,\ a number of organizations concerned with the education of physicians and o\ ther health-care providers have developed medical and nursing school curricul\ a that reflect an awareness of the importance of paying close and sensitive a\ ttention to the patient’s cultural and linguistic heritage and its role in their \ health. For exam- ple, the Society of Teachers of Family Medicine developed and has contin\ ued to update the “Core Curriculum Guidelines on Culturally Sensitive and Co\ mpetent Health Care.” These guidelines were motivated by the view that “un\ derstand- ing .  .  . sociocultural variables in health care settings will facilitate the cl\ inical encounter toward more favorable outcomes and enhance the potential for a\ more rewarding interpersonal experience” (Like et  al. 2017). Various medical and other health education institutions in the United States and elsewhe\ re have adopted elements of these kinds of tools into their educational curricul\ a. In the view of one physician advocate of culturally competent training of healt\ h-care Collating Cultures in Biomedical Care One expression of the new medical sensitivity to culture is the notable pop- ularity of Anne Fadiman’s (1997) com- pelling and very touching book The Spirit Catches You and You Fall Down:

A Hmong Child, Her American Doctors, and the Collision of Two Cultures, which has become the most widely used text in cultural competence training for health- care practitioners, including many first- year medical students, in the United States. The book recounts the story of Lia Lee, a Hmong child who was born in Merced, California, in 1982. At three months of age, Lia began having intense seizures, which were interpreted as signs of “soul loss” by her parents and a Hmong shaman but diagnosed by her biomedical doctors as epilepsy. Convinced that Lia’s parents were not administering the medicines they pre- scribed because of their faith in Hmong ethnomedicine, Lia’s doctors launched a successful effort to remove her to fos- ter care. Only after a year of battling the system were Lia’s parents able to have their daughter returned home. Ultimately, Lia suffered a massive seizure that left her permanently brain damaged. By poignantly describing a fatal clash of cultures in medicine, Fadiman’s book has made clear to many why culture is so important in the practice of medicine (though some have criticized the book for presenting an overly static “fixed-in- time” view of culture rather than seeing it as a moving process that is created and changed as it is used). Health Disparity, Health Inequality 113 providers, “Cultural competence means understanding beliefs of your p\ atient, and reaching into those beliefs to better understand their perception of\ their illness or treatment, to give them comfort or to give them what they nee\ d, so that they can either make it through treatment or perhaps let go” (quoted in Meldrum 2010:94). These changes, at least in part, reflect the impact of health anthropo\ lo- gists who work in clinical settings within the subfield of health anth\ ropology called clinical anthropology or clinically applied anthropology. Exempla\ ry of the anthropological contribution to cultural competence in health care i\ s a two-volume set produced by the California Endowment. Edited by anthropol\ ogist M. Jean Gilbert (2003a, 2003b) of California State University–Long \ Beach, these manuals include a set of principles and recommended standards for cultur- ally competent health-care education, a resource guide, and a manager’\ s guide for running a culturally competent health-care institution. The manuals \ illus- trate once again an important way in which health anthropology is a disc\ ipline in action actively seeking to address pressing issues in health. Another exam- ple, from Australia, demonstrates the practical collaboration of anthropology with people from the health professions and public agencies. The Intercu\ ltural Interaction Project in the School of Occupation and Leisure Sciences at \ the University of Sydney involves health science students, and organizations\ such as the Transcultural Mental Health Centre in Sydney have produced classr\ oom and workshop training materials and teaching models to enhance the cultu\ ral competence of health professionals. From this work has developed the ide\ a that cultural competency can be considered as being of three types: culture specific, intercultural, and culture general (Fitzgerald 2000). The emphasis in \ this work on culture general competence highlights issues particularly in relation\ to mul- ticultural societies, which with global migration is now most societies,\ where there is a need to recognize that cultural issues in the provision of health care and social services arise and must be addressed for all people, not just\ minority ethnocultural communities.

Health and Social Disparities Cross-Culturally Health disparities are not peculiar to the United States or to the Weste\ rn world but are a global problem. Internationally, there are two expressions: di\ sparities between wealthier and less wealthy nations and disparities within the po\ pulations of all nations around the world. Regarding the first of these, the Hea\ lth Evidence Network of the World Health Organization (2006b) notes that over the past several decades the number of people in the world living on less than $2\ per day has grown to almost three billion. Further, income disparities between t\ he rich and the poor around the world are growing. While the income of the riche\ st 20 percent of the population in the world was thirty times that of the p\ oorest 20 percent of the population in 1960, today it is eighty-two times greater. Within this context of an ever-wider gap between the rich and the poor, health dispari- ties are driven by factors such as social exclusion and discrimination, \ inadequate diet and malnutrition, a rapid reemergence of both waterborne and blood-\ borne 114 Chapter 4 infectious diseases, poor housing, low-status employment, unhealthy early child- hood living conditions, degradation of the physical environment, disinvestment in the public health and health-care infrastructure serving the poor, es\ calating violence, and lack of health insurance (figure 4.1). One way to get a better understanding of health disparities across natio\ ns is to compare the top causes of death between a wealthy nation such as the \ United States and worldwide, as seen in table 4.1. It is evident from reviewing\ this table that, aside from the high ranking of heart disease and cerebrovascular d\ isease (stroke) as well as unintended injuries, the primary causes of death in the United States and the world as a whole are quite different. Of even greater sig\ nificance from the standpoint of health disparities is the fact that while chronic\ conditions dominate the United States, a number of acute conditions and diseases that could be treated if appropriate health care were available (i.e., disea\ ses marked by an asterisk in the table) dominate the global list. In other words, \ if health care were equitably distributed in the world, millions of people around the p\ lanet would not be dying of diseases for which cures and treatments already ex\ ist. A critical factor contributing to health disparities around the world is\ the emergence of new infectious diseases and new vector-borne diseases. Infectious diseases—diseases whose immediate cause is a pathogen, such as viruse\ s, bacteria, protozoa, or helminthes—are on the rise and kill millions of people e\ ach year, particularly in resource-poor nations. The era of “new diseases” b\ egan with the FIGURE 4.1 Backyard pond in East Medinipur District, West Bengal, India, in which this fam- ily must bathe, fish, clean fish, and wash dishes and clothes. Photo by \ Anna Marie Nicolaysen. Health Disparity, Health Inequality 115 appearance of AIDS in the early 1980s, followed quickly by the emergence\ of SARS, Ebola, hantavirus, Rift Valley fever, Zika, and a rising tide of o\ ther new or renewed infections (i.e., diseases that had been brought under some con- trol but have since reemerged, often in more virulent form, and are resi\ stant to the drugs that had once controlled them). One such reemergent diseas\ e, tuberculosis, often associated with AIDS (a combination most frequently seen in the poorest populations), has become one of the world’s greatest \ causes of mortality linked to an infectious agent. Vector-borne diseases (those s\ pread by a blood-sucking arthropod such as a mosquito), including malaria, de\ ngue, yellow fever, plague, filariasis, louse-borne typhus, trypanosomiasis,\ and leish- maniasis, also have become an ever more important source of health dispa\ rities in the world. In 2015, the global number of new malaria cases was 212 mi\ llion including 429,000 deaths. Across Africa, in particular, millions of peop\ le still lack access to the resources that are needed to prevent and treat this diseas\ e. Inade- quate funding and fragile health-care systems block people’s access t\ o life-saving interventions like bednets. According to the 2016 World Malaria Report (\ World Health Organization 2017b), less than half of the ninety-one malaria-af\ fected countries and territories in the world are on track to achieve the 2020 \ global health goal of a 40 percent reduction in case incidence and mortality. Various factors have contributed to the changing profile of infectious\ diseases in the world, including the breakdown of public health prevention system\ s in poorer countries; the social disinvestment in health in debt-ridden nati\ ons under pressure from development banks and wealthy lender nations; the increase\ d concentration of people living in megacities with huge impoverished popu\ lation sectors living in overcrowded, unhygienic conditions; the frequent movem\ ent of populations fleeing low- and high-intensity wars and other military th\ reats; the Top Ten Causes of Death in the United States and Worldwide United States Worldwide 1. Heart disease 1. Heart disease 2. Cancer 2. Cerebrovascular disease 3. Stroke (cerebrovascular disease) 3. Acute lower respiratory infections* 4. Chronic lower respiratory diseases 4. Chronic obstructive pulmonary disease 5. Unintentional injuries 5. Diarrheal diseases 6. Diabetes mellitus disease 6. HIV/AIDS* 7. Pneumonia and influenza 7. Tuberculosis* 8. Alzheimer’s disease 8. Lung/bronchial/tracheal cancer 9. Nephritis 9. Unintentional injuries 10. Septicemia 10. Premature birth and low birth weight Sources: Centers for Disease Control and Prevention and World Health Organizatio\ n.

*Acute diseases that are treatable if health care is available.

TABLE 4.1 116 Chapter 4 rapidity of global travel made possible by jet aircraft; the global move\ ment of consumer products that can harbor infectious agents; the environmental discard of nonbiodegradable products such as worn-out tires that become mosquito breeding sites in the rainy season; deforestation; and, increasingly, en\ vironmental change associated with global warming.

Child and Maternal Health Disparities An important measure of health internationally, one that is used commonly to assess the health status of a nation, is the general health and well-bei\ ng of young children and their mothers. The WHO reports that more than ten million c\ hil- dren and more than five hundred thousand mothers die each year, mostly\ from preventable causes. These numbers suggest the painful significance of \ health problems in the world today, usually rooted in social marginality, pover\ ty, and powerlessness, despite tremendous national and international efforts to \ make the world a healthier place (figure 4.2). In addition to reducing diarrhea-related diseases through the distributi\ on of a simple oral solution for rehydrating children with diarrhea, internati\ onal health efforts focused on childhood immunization against major infectious disea\ ses such as tuberculosis, diphtheria, pertussis, tetanus, measles, and polio\ myelitis.

As Justice (2000:25) observes, these “two technological interventio\ ns—oral rehydration and immunization—emerged as the twin-engine approach to child health and reducing infant mortality” (figure 4.3).

FIGURE 4.2 Family awaiting the demolition of their home in slum clearance in Dhaka,\ Bangladesh. Photo by Sabina Faiz Rashid. Health Disparity, Health Inequality 117 As a result of these efforts and the investment of resources in child survival, the rate of mortality of children under five years of age fell through\ out the world during the latter part of the twentieth century, going from 146 per 1,00\ 0 popula- tion in 1970 to 79 per 1,000 population in 2003. Between 1990 and the pr\ esent, the rate of childhood death dropped by about 15 percent, resulting in the lives of two million children being sheltered from death in 2003 alone. As the\ mil- lennium was ending, however, the general global downward trend in childh\ ood mortality began to level off. In the years between 1970 and 1990, the mo\ rtality rate of children under five years of age dropped by 20 percent every decade; by contrast, between 1990 and 2000, it dropped by only 12 percent. This slo\ wdown signaled shifts in relations among richer and poorer nations, a fact tha\ t is revealed by moving from global averages to an assessment of regional differences \ in child mortality. In two regions of the world, Africa below the Sahara Desert a\ nd the western Pacific, the slowdown in the tempo of deaths among children un\ der five years of age began during the 1980s. Sub-Saharan countries of Africa beg\ an the last thirty years of the twentieth century with the highest levels of un\ der-five child mortality, witnessed the smallest reductions (about 5 percent per decad\ e between 1980 and 2000), and displayed the most marked slowdown in the process o\ f improving children’s health by the end of the century. By contrast, p\ rogress in reducing childhood mortality continued or even accelerated in the Americ\ as, Europe, and Southeast Asia throughout the period of concern. As reflected in these statistics, disparities in the health of childre\ n in richer and poorer countries around the world have been growing in recent years.\ FIGURE 4.3 Two mothers with sick children from the Dani people of Papua New Guinea.

Photo by Leslie Butt. 118 Chapter 4 The mortality rate for children under five years old is now seven times higher in sub-Saharan Africa than it is in Europe. In 1980, it was just over fo\ ur times higher. Indeed, child death in the world increasingly is concentra\ ted in sub-Saharan Africa, where 43 percent of the global total of child mortal\ ity is found, reflecting an increase of 13 percent between 1990 and 2003. Ano\ ther 28 percent of child deaths occur in Southeast Asia. Indeed, more than ha\ lf of all child deaths in the world occur in just six countries: China, the Democratic Republic of the Congo, Ethiopia, India, Nigeria, and Pakistan. Even short of actual mortality, disparities in children’s health cros\ s-culturally are telling. For example, 6 percent of children around the globe are bor\ n with serious birth defects. More than 90 percent of births with serious defec\ ts are found in middle- to low-income countries (March of Dimes 2006). Povert\ y has been found to be one of the most important factors in birth defects \ inter- nationally; other factors include the mother’s age, marriage among cl\ ose blood relatives, and living in the “malaria belt” of countries with sign\ ificant levels of malaria in which inherited diseases such as sickle cell disease, thalassemia, and glucose-6-phosphate dehydrogenase deficiency are most common. Simi\ lar sociogeographic disparities are found in childhood nutritional status an\ d nutrition-related health conditions, according to the WHO. From 1990 to \ 2000, the global prevalence of both growth stunting (due to poor diet) and b\ eing underweight dropped by 20 and 18 percent, respectively. But high rates o\ f mal- nutrition among children and other nutrition-related health and physical\ symp- toms continue in southern and central Asia and sub-Saharan Africa. For c\ hildren in particular, the planet increasingly is a world divided between compar\ atively wealthy and comparatively poor places, and where you are born is a major\ deter- minant of what will happen in your life, including the likelihood that y\ ou will live beyond your fifth birthday. One of the key forces impacting the health of children around the world \ is the condition of the environment in which they live, including the quality of the air they breathe, the water they drink, the food they eat, and the hidden threats\ that lurk in the areas in which they play, issues that will be addressed more fully in chapter 7.

Children are at particular risk from environmental toxins because their \ brains, ner- vous systems, and immune capacities are still developing and because exposure to environmental poisons can cause lifelong damage and chronic disadvant\ age.

Air pollution, for example, both outdoors and within the home, is a prim\ ary cause of acute lower-respiratory infections in children, especially pneumonia \ (figure 4.4). Such infections are among the major sources of mortality among young children, causing more than two million deaths each year, the vast major\ ity in resource-poor nations. Similarly, lack of access to clean water is common in poorer countries. Each year, diarrhea disease, a consequence in part of \ unclean drinking water, takes the lives of 1.5 million children. Moreover, it is\ estimated by the WHO (2006a) that 2.5 billion people, most of them in poor count\ ries, lack access to adequate sanitary facilities. War and internal conflict are also forces impacting children’s heal\ th inter- nationally (figure 4.5). Countries that have been ravaged by interna\ l wars, such as Sierra Leone, Angola, Afghanistan, Liberia, and Somalia, tend to have\ the highest child mortality rates in the world. In Sierra Leone, for example\ , 250 of Health Disparity, Health Inequality 119 FIGURE 4.4 Factory air pollution is a source of respiratory disease. Photo by Merrill Singer.

FIGURE 4.5 Tibetan orphan in front of the Medical Care Unit at the Tibetan Homes Foundation in Uttarakh, India. Photo by Anne Marie Nicolaysen. 120 Chapter 4 every 1,000 children die before they reach their fifth birthday, compa\ red to 8 per 1,000 in the United States, according to UNICEF. Since 1990, 90 perc\ ent of conflict-related deaths have been civilians, and, of these, 80 percent have been women and children. UNICEF reports that in a typical war, the death\ rate among children under five years of age goes up by 13 percent. War\ s often take a significant toll on health facilities and other societal infras\ tructure, loss of which is especially damaging to the most vulnerable sectors of a popu\ lation.

Moreover, many children are left orphaned, and others are abducted to be\ used as soldiers or are raped or otherwise injured. The emotional scars from \ exposure to violence, loss of family members, dislocation from their homes, and r\ esulting impoverishment can be lifelong. Typical is Sumaya, a fifteen-year-old \ girl from Sudan whose village was attacked by an Arab tribal militia force called \ the Jan- jaweed. Sumaya was interviewed by UNICEF workers in the Kalma refugee camp in South Darfur: “I was at school when they attacked us,” says Sumaya. “My sisters ran back to the village, and I ran with some friends. My cousin Mona was running ahe\ ad of me when she was shot. I stopped and held her hand. When she died, her hand slipped out of mine. Some boys came and told me that I had to run, \ so I did.” Along the way Sumaya found her grandmother and her 4-year-old b\ rother, Mozamel (whom everyone calls Baba). She took the little boy in her arms and started running. “We ran and ran until I felt that I couldn’t go o\ n any longer,” remembers Sumaya. “I thought about throwing my brother in the grass b\ ecause he was so heavy, but my grandmother took my hand and told me that we sho\ uld all stay together.” Two agonizing weeks went by before Sumaya and Bab\ a were reunited with the rest of the family. Together, they walked 147 kilometres to Kalma Camp [along with 70,000 other refugees]. (UNICEF 2006) Despite major international efforts and significant initial improvemen\ ts in child health, continued improvements in rates of success have not bee\ n sustained, nor have they been equitably distributed across the nations o\ f the world. In Justice’s (2000) assessment, several factors are importan\ t. While international funds were made available to cover initial costs of improv\ ing maternal and child health, individual countries were required to use the\ ir own resources to implement programs at the local level. Poorer countries wit\ h lim- ited human and financial resources were unable to meet all the local c\ hallenges of program implementation. The international community, moreover, failed\ to recognize the fragile nature of the health systems and scarcity of re\ sources (e.g., availability of trained personnel in local settings) in poorer \ countries.

Additionally, immunization was tested in a number of small-scale pilot p\ rojects without full consideration of how to scale up immunization in resource-p\ oor nations. Finally, the international health priorities and programs shift\ from year to year, leaving earlier programs, such as childhood immunization, on th\ eir own without international support, leading to drops in immunization rate\ s in many countries. In other words, from Justice’s perspective as a health anthropologist\ trained to shift her analytic lens between the macrolevels and microlevels in hu\ man social systems, overemphasis on a top-down approach, inadequate attentio\ n to Health Disparity, Health Inequality 121 disparities in national health resources, and failure to recognize local\ diversity within nations became important barriers to sustained improvements in ch\ ild health. In the following section on globalization (see chapter 5), we \ will consider some other factors as well. One final indicator of health disparities across nations is access to \ health insurance. Lack of health insurance among the poor globally is an especi\ ally damaging problem. According to the World Health Organization, Insurance protects people against the catastrophic effects of poor healt\ h. What we are seeing is that in many countries, the poor pay a higher percentag\ e of their income on health care than the rich. . . . In many countries without a health in- surance safety net, many families have to pay more than 100 percent of t\ heir in- come for health care when hit with sudden emergencies. In other words, i\ llness forces them into debt. (World Health Organization 2000) Addressing Health Disparities In a keynote address at the 2004 International Conference on Overcoming \ Health Disparities: Global Experiences of Partnerships between Communiti\ es, Health Services and Health Professional Schools, David Satcher (2004),\ the former surgeon general of the United States, noted that to eliminate hea\ lth dis- parities globally, we must “know enough” (i.e., carry out much-ne\ eded research on existing health disparities and their causes), “do enough” (i\ .e., deliver desired outcomes in terms of removing barriers to health-care access, eliminatin\ g the social causes of poor health among disparity populations, and implementi\ ng culturally competent care), “care enough” (i.e., have the commit\ ment needed to accomplish desired goals), and “persevere enough” (i.e., recogni\ ze that the elim- ination of health disparities is a long-term objective and avoid discour\ agement).

Each of these agenda items for achieving global health equity represents\ a major challenge for policy makers, health-care providers, consumers, and the fi\ eld of health anthropology. Health disparities have become an area of concern to the work of a growi\ ng number of health anthropologists. In particular, health anthropologists \ who are active in this arena have been attempting to understand biocultural and \ bioso- cial interactions as causes of health inequality and marshaling research\ findings on these connections in the development of targeted intervention program\ s intended to reduce or eliminate disparities.

Addressing Health Disparities in the Community One issue that continues to come up in applied health work is the issue \ of access to health insurance among people who are at or below the official fede\ ral poverty line. Is the federal implementation of universal health-care coverage th\ e answer to this problem as it has been in countries such as Canada, the United K\ ingdom, and Australia? A related question that applied health anthropologists mu\ st ask is whether it is possible to achieve universal health care in the United\ States.

It would seem so, given the vast resources of the nation and the fact th\ at other 122 Chapter 4 countries have been able to implement programs designed to cover the hea\ lth- care costs of all residents. Yet, there has been tremendous resistance t\ o this idea historically in the United States, especially from the powerful insuranc\ e industry and other wealthy sectors of society. The nature of this opposition was \ played out during the Barack Obama administration in efforts to implement some \ form of accessible insurance coverage through the Affordable Care Act. While \ this limited bill did bring coverage to millions of people, it was firmly r\ esisted by political conservatives, who scrambled to eliminate it—despite repeat\ ed national polls indicating its popularity—and roll back all federal assistance \ for essential health coverage for the poor, seniors, women, and others with the electi\ on of Donald Trump. As this example suggests, the elimination of health-care disparities is not easy because it would involve significant social changes that are \ not sup- ported by sectors of the society that benefit from the existing way so\ ciety is organized. As Townsend (1986) argued in what is now a classic article \ in the literature on health disparities, it is not simply the case that there a\ re rich and poor in the world; instead, there are rich precisely because there are p\ oor.

Consequently, to eliminate health disparities he argues that it is neces\ sary “to restrict the power and wealth of the rich, to dismantle the present stru\ ctures of social privilege, and to build social institutions based on fair allo\ cation of wealth and on social equality” (Townsend 1986:29). More recently, C\ her- nomas and Hudson (2010) noted that historical broad health and social inequality has been justified by the claim that the poor are intellect\ ually and behaviorally inferior to the rich. While this assertion is no longer mad\ e, at least publicly, the wealthy tend to maintain that redistribution of wealth is unnecessary because a free market will efficiently and justly distribu\ te income among members of society. This neoliberal argument, which Chernomas and Hudson refer to as “the myth of conservative economic policy,”\ has not proven to eliminate either health or social disparities, suggesting the \ accuracy of Townsend’s proposition.

Upstream Analyses of Health Disparities A critical role that health anthropologists can play in addressing the i\ ssue of health disparities emerges from the broad, holistic perspective of anthr\ opology.

To date, much of the work that has been done on health disparities that \ analyzes the “social determinants of health” tends to frame its discussion \ of causal factors in terms of intermediate-level issues, such as poverty, local or neighbo\ rhood conditions, malnutrition, and SES, without embedding these variables in \ a more expansive macroscopic context. However, critical health anthropology posits the ultimate determinants of health in the capitalist world system, one that started out in Europe so\ me five hundred years ago but has diffused to every human-inhabited region of th\ e globe (Baer et al. 2013). Global capitalism has progressively impacted and shaped and reshaped social life, including health and access to health care. Given \ this macro- scopic reality, CHA seeks to examine health-related issues within the context of class, racial/ethnic, and gender and imperialist relations inherent in t\ he capitalist Health Disparity, Health Inequality 123 world system and seeks strategies to transcend them, which we discuss in\ the concluding chapter. Two very important books have moved beyond an intermediate-level focus. \ Additionally, they address a key question about disease causation: “J\ ust because most diseases have a social connection of some type, does not necessaril\ y mean that such links can actually cause a disease to occur—or does it?”\ (Cockerham 2013:2). Both books, like critical health anthropology generally, answe\ r this query about the dominant forces shaping global health in the affirmati\ ve. Central to these forces is “the growth of inequalities between the rich and t\ he poor in countries around the world” (Parker and Sommer 2011:1), inequalitie\ s between countries, and other factors like gender or minority status that are oft\ en entwined with wealth inequality. Inequality contributes to the contemporary signi\ ficant disease burden of lesser developed countries consisting of communicable \ diseases (such as Ebola, tuberculosis, or HIV), noncommunicable diseases (such\ as dia- betes, cardiovascular problems, and most cancers), and behavior disorde\ rs linked to alcohol and drug abuse. The first of these books, Dying for Growth, emanated from the collaborative work of an interdisciplinary team based at the Institute of Health and S\ ocial Justice in Cambridge, Massachusetts (Kim et  al. 2000). One of the editors of this volume is Jim Yong Kim, a physician, health anthropologist, and hea\ d of the World Health Organization, and another editor, Joyce Millen, also a \ health anthropologist, is on the faculty of Willamette University. This importa\ nt anthol- ogy explores the linkages between neoliberalism or late global capitalis\ m and health problems among the poor in various countries. In its various essa\ ys, Dying for Growth argues that the World Bank’s policy of “structural adjustment,”\ which has fostered privatization of social and health services in developing c\ ountries, has in turn adversely affected the poor around the globe. Further, the b\ ook explores the adverse impact of the practices of transnational corporatio\ ns (those that have operations in multiple countries) on the health of the poor, \ such as in the case of the 1984 Bhopal gas disaster in India and the harsh working \ condi- tions experienced by maquiladora workers who are employed in factories o\ wned by American companies that were built just over the border in Mexico. The second book that provides a macroscopic perspective on health dispar\ i- ties is Global Inequality and Human Needs by Laurie Wermuth (2003), a medical sociologist who adopts a political economic perspective in her examinati\ on of regional trends in world health; the impact of gender, race, and ethnici\ ty on both physical and mental health; and the relationship between economic develo\ pment and health. She argues, Among the social factors that influence health and life chances is locat\ ion in the global economy. Economic projects designed by capitalists in affluent pa\ rts of the world have ripple effects in the countries where the production occu\ rs. . . . A person’s location in this global economic web of production and con\ sumption is likely to influence how well he or she is fed, clothed, and housed, a\ nd what kinds of educational and occupational opportunities he or she has. (45–\ 46) Obviously, social factors such as food, clothing, shelter, and education\ al and occupational background play an important role in people’s health and\ access 124 Chapter 4 to health care. By “looking upstream” to the factors (e.g., socia\ l policies) and unequal social relationships that ultimately determine health disparitie\ s, health anthropologists can help seek effective responses to health inequality.

Gender and Global Health Gender, a socially constructed distinction between the social position, authority, rights, and access to resources between men and women in society, is an \ import- ant dimension of global health. Much of the focus on gender and health h\ as been on women’s health. Globally, women experience a disproportionate burd\ en of both disease and death as a consequence of inequities in access to basic\ health care, nutrition, and education. Gender influences exposure to health r\ isks, ability to learn about health information, access to treatment, and health outco\ mes.

As the World Health Organization reports (2013), noncommunicable disea\ ses, including cardiovascular disease, cancer, diabetes, and chronic respirat\ ory disease, are the leading causes of death among women globally and cause two-third\ s of deaths among women annually. While these are also diseases of men, disea\ ses often impact women and men differently. Women who die suddenly of heart disease, for example, are less likely than men to experience previous sy\ mptoms. Additionally, girls are far more likely than boys to suffer sexual abuse\ . Ado- lescent girls and young women (fifteen to twenty-four years) face double the risk of HIV infection compared to boys and young men in the same age gro\ up.

This higher risk level is linked with unsafe and often unwanted and forced sexual activity. HIV and other sexually transmitted diseases pose a heightened \ threat to women and put them at special risk because of an interrelated set of bio\ political factors, hormonal and immunological factors, on the one hand, and povert\ y, gendered power relationships, and violence, on the other (Ostrach and S\ inger 2012). It is estimated that 35 percent of women worldwide have experien\ ced either intimate partner violence or nonpartner sexual violence in their \ lifetime.

Further, work assigned to women, such as getting water, may place them a\ t spe- cial threat for certain diseases and injuries. Anemia, especially iron-deficiency anemia, is common among adolescent girls in poorer countries and is known to increase the likelihood that h\ emor- rhaging and sepsis will occur during childbirth. In poorer nations, deat\ h during pregnancy and delivery is a major threat. Preterm birth complications ar\ e ranked as the tenth leading causes of disability of women, while maternal death\ is the second biggest killer of women of reproductive age. Indeed, among women \ of childbearing age, the health risks associated with pregnancy and childbi\ rth are the leading causes of death, disease, and disability internationally. Mo\ re than three hundred million women in poorer and less-developed countries suffe\ r from short-term or long-term illness brought about by pregnancy and chil\ d- birth, according to the WHO, and there are few indicators that improveme\ nts are occurring in these areas. Indeed, in some parts of the world, the he\ alth of mothers is falling. Not surprisingly, maternal death is especially commo\ n in poorer countries, especially in sub-Saharan Africa, with less than 1 per\ cent of maternal deaths in the world occurring in wealthy countries. While the lifetime risk of maternal death is 1 in 16 in the world’s poorest nations, it \ is 1 in 2,800 in Health Disparity, Health Inequality 125 the world’s wealthiest nations. In some settings, such as parts of La\ tin America, women experience neglect and even abuse in health-care institutions, a p\ henom- enon that has been called “obstetric violence” (Dixon 2015). In sum, there are multiple ways in which girls and women face special he\ alth risks, yet neglect of women’s health is common in many societies.

Focusing on Disparity in Diseases One health anthropologist who has been quite active in addressing gender\ - related health disparity issues over time is Deborah Erwin, the director\ of health disparities at the Roswell Park Cancer Institute in Buffalo, New York. M\ uch of Erwin’s career has focused on reducing and preventing health disparities in can- cer. She has worked for many years developing culturally appropriate pro\ grams to enhance access and screening for cancer among minority and underserve\ d populations. As part of this work, Erwin helped develop the Witness Proj\ ect, a breast cancer education and screening intervention specifically target\ ed to Afri- can American women. The Witness Project model has been replicated in ove\ r thirty sites in twenty-two states. At the heart of the project are Afric\ an American women living with cancer who share their personal narratives with patien\ ts with a more recent diagnosis of cancer. These narratives affirm that “Af\ rican Ameri- can women are not helpless as patients in the biomedical system [and str\ ess] the fact that other sisters can help navigate the process, much like shaman \ traversing unknown worlds.” Moreover, they call attention to the need “to rec\ ognize and address the social justice issues and social determinants integrated int\ o cancer detection, treatment, and causation” (Erwin 2008:144–45). In another applied project, Erwin and colleagues (Jandorf et al. 2014) focus on reducing disparities in breast and cervical cancer for Latinas in Ark\ ansas, Buffalo, New York, and New York City. Participants were randomly assigned to group educational programs on either cancer or diabetes screening. They \ found that involvement in educational programs significantly increased getti\ ng mam- mography, clinical breast exams, and Pap tests, with no significant di\ fferences by message type. These researchers concluded that the specific health \ messaging may not be as important to increasing breast and cervical cancer screeni\ ng as cultural- and language-specific outreach in the community. Another health anthropologist who works on cancer as a health disparity \ issue is Christine Makosky Daley of the University of Kansas Medical Sch\ ool.

Her primary areas of research focus are the reduction of health disparit\ ies in Native North America through primarily cancer control and prevention and\ cross-cultural communication in the health-care setting, and by way of c\ ommu- nication technology (Choi et al. 2011, Daley et al. 2012). In addition to working on other applied health anthropology projects, Daley has worked as the p\ roject director on an American Lung Association–funded assessment of a smoki\ ng cessation program culturally tailored for American Indians and Alaska Na\ tives.

Although American Indians and Alaska Natives have the highest smoking ra\ tes in the country, few smoking cessation interventions are specifically t\ argeted to these populations. She subsequently began working on a culturally target\ ed smoking cessation program with the Haskell Health Center and the urban N\ ative 126 Chapter 4 American population in Kansas City. Also of concern in her work are barr\ iers to cancer screening faced by Native Americans. Based on this concern, she w\ orked with the Fort Apache Indian community in Arizona, where she helped to im\ ple- ment the Well Woman Healthcheck Program, a program of mobile breast and \ cervical cancer screening. In addition to this work, Daley helped to dev\ elop a touch-screen computer system to increase patients’ open and relaxed d\ iscussion of colorectal cancer screening with their physicians.

Multidisciplinary Approaches In his work at Northwestern University, Thomas McDade focuses on under- standing health and human development in the context of social and cultu\ ral processes, with a particular emphasis on the role of stress in the devel\ opment of disparities in health. For example, McDade (2003) has studied the i\ mpact of stressful life events on the function of the immune system among Samoan \ ado- lescents. Additionally, McDade helped develop Cells to Society (C2S), \ a center for innovative, multidisciplinary approaches for studying health disparities. Spe- cifically, C2S was developed to unite the social, life, and biomedical\ sciences in expanding the understanding of the origins and consequences of health in\ equal- ities in the United States and using this information to generate policy\ solutions.

Of special interest to McDade and other researchers at the center is how\ broad social, ethnic, and economic disparities “get under the skin,” suc\ h as through the impact on the immune system, and affect human development, psycholog\ ical well-being, and longevity. One potential pathway through which psychosocial stressors increase the \ risk for cardiovascular disease is chronic inflammation. However, McDa\ de and colleagues (2013) from several disciplines found that prior research on stress and inflammation was conducted almost exclusively in high-income, industri\ alized populations that have low levels of infectious disease. Consequently, th\ ey carried out their research among young adults in the Philippines who have grown \ up in an ecological and epidemiological setting substantially different fro\ m that of high-income Western countries. Their results suggest that early environm\ ents influence the development of inflammatory phenotypes in ways that mo\ derate sensitivity to psychosocial stressors in adulthood, and they support the\ impor- tance of carrying out comparative, developmental research on social envi\ ron- ments, inflammation, and disease.

Studying Local Mediation of Global Health A final example of the roles health anthropologists play in health dis\ parities is seen in the work of Lee Pachter, whose research has focused on accountin\ g for patterns of health disparities among children, among other related t\ opics (Pachter 2006). In his research with inner-city populations, he has ar\ gued that purely economic indicators, such as household income, do not fully account for the unequal distribution of health and illness among childre\ n.

In addition, he has shown that residential segregation and the number of\ Health Disparity, Health Inequality 127 urban poor families living in concentrated poor neighborhoods is of crit\ ical importance. Pachter identified three mechanisms through which resident\ ial segregation magnifies child health disparities: (1) having to pay hi\ gher prices in smaller neighborhood stores while having limited employment opportu- nities; (2) the breakdown of interpersonal cooperation for mutual bene\ fit with resulting loss of interpersonal trust and community participation; \ and (3) enduring exposure to structural violence (e.g., racism and discri\ mination) giving rise to psychological deficits, such as low self-esteem, a low \ sense of self-efficacy, and disempowerment. The interconnectivity and mutual re\ in- forcement of these factors produces heightened rates of poor health amon\ g the children of households in highly concentrated poor neighborhoods. As\ a pediatrician/anthropologist, Pachter is able to translate his findings\ into hos- pital-based programs to improve the health of poor children. In more recent work, Wade and colleagues (2017) examined the lifetime \ health effects of adverse childhood experiences (ACEs). Traditionally, such expe- riences have been limited in research to the enduring negative health ef\ fects of various aspects of family dysfunction. In their work, these researchers \ emphasize the importance of adding community-level variables such as community vio\ - lence, urban crowding, and perceived racism. In research using this expa\ nded definition, it was found that elevated family dysfunction ACE scores were signifi- cantly associated with adult health risk behaviors, and physical and men\ tal illness (Bethell et al. 2017). High community-level ACE scores, in turn, were associated with substance abuse history and suffering from a sexually transmitted i\ nfection.

These results support an understanding of the primacy of family relation\ ships on a child’s health life course and the need for specifically targe\ ted interventions designed to support families living under adverse conditions in socially and eco- nomically marginalized neighborhoods. As this discussion suggests, with reference to public health, “place \ mat- ters.” Indeed, this is the title of one of the seven episodes in the \ widely viewed public health documentary video Unnatural Causes: Is Inequality Making Us Sick?, produced by California Newsreel (see www.u nnatu ralca uses. org/ e pisod e_des cript ions. php?p age=5 ). As this educational program emphasizes, people’s street address is a good predictor of their health status. E\ xemplary is the economically depressed city of Richmond, California. During World\ War II, Richmond had been a boomtown, with the local shipyards turning out ships for the war effort twenty-four hours a day. But at the end of \ the war the shipyards shut down, throwing workers into unemployment. White fami- lies were able to take advantage of federally backed home loans and move\ to the suburbs, but because of overt discrimination this was not the case f\ or eth- nic minorities. The result was the emergence of a legacy of poverty and poor health in places like Richmond. Today Richmond has high rates of asthma hospitalization and diabetes and a lower life expectancy than suburban a\ reas.

Research indicates that in places like Richmond, there is a 50 to 80 per\ cent increase in risk for heart disease related to chronic stress. Additionally, while fresh fruits and vegetables are hard to find locally, tobacco, liquor,\ and fast foods are readily available. 128 Chapter 4 Pushing Back on Health Disparities Communities do not often passively accept significant health dispariti\ es. Rather, they find ways, large and small, visible and more hidden, and perhaps \ not always articulated in the language of health, to resist and fight back agains\ t health inequality and injustice. One such strategy was identified in a study \ of inner-city community perceptions of being stigmatized due to suffering from food in\ secu- rity and living in a food desert, a term used to refer to marginalized sections of cities with few if any supermarkets. Residents who were interviewed abou\ t the difficulties they faced in providing healthy food for their families, \ and the stigma they endured because of it, reported resistance in the form of taking pr\ actical if difficult steps such as riding a bus to distant areas of the city to s\ hop at full-service grocery stores. While this was very time-consuming for them and somewhat\ of a burden in light of the planning involved, participants “expressed a d\ etermination to seek the best possible nutrition for their families and to not let th\ emselves fall victim to nutritional exclusion” (Xu et al. 2016:1306). At a broader scale, a review of published studies (Anderson et  al. 2015) found that interventions targeted at addressing the unequal health statu\ s of eth- nic minority populations that are led by community coalitions can build \ alliances among health and human service providers and ethnic racial minority comm\ uni- ties in ways that contribute to improved health outcomes and behaviors, \ as well as to enhanced quality of the care delivery systems. Community coalition\ s are created when a lead community agency or other convening group takes acti\ on on a community health issue (e.g., disproportionate rates of diabetes)\ . Other organizations and residents in the community are attracted by the initia\ tive, which sometimes leads to or is the result of a funding opportunity (e.g\ ., gov- ernment funding for community-based obesity prevention) or sometimes from a mandatory requirement by the funding source (like the Robert Wood Joh\ n- son Foundation’s funding of the Fighting Back Initiative to reduce th\ e use and abuse of alcohol and illicit drugs). Governments and foundations have c\ ome to see community coalitions as a means of reducing costs and duplication of\ effort through merging of resources at the local level where interventions are \ intended to have an impact. Communities may see coalitions as challenging but eff\ ective ways to address the health disparity issues they perceive as most pressi\ ng.

“Race” and Health Disparity One of the debates over health disparities concerns the role of genetics\ and race as determinants of health status. For example, it is known that thr\ ough- out the Americas, “people of African ancestry have higher blood press\ ures and higher rates of hypertension than do others in the same societies”\ (Grav- lee et  al. 2005:2191). Hypertension plays a major role in lowering the life expectancy of African Americans in the United States—more so than can\ cer, diabetes, stroke, or AIDS—and this is true elsewhere in the Americas \ among people of African origin. Moreover, among African Americans, those with darker skin color tend to have higher blood pressure than those with lig\ hter Health Disparity, Health Inequality 129 skin color. One hypothesis about why this might be so is that dark skin \ color is a visible marker of African ancestry and reflects a genetic, race-b\ ased pre- disposition for higher blood pressure. To test this hypothesis, Gravlee \ and coworkers (2005) conducted a study in Guayama in southeastern Puerto Rico in which they first used cultural consensus analysis to determine\ local study participants’ assessment of the color of seventy-two standardiz\ ed facial portraits that varied by skin tone, hair texture, nose shape, and lip fo\ rm. This led to the identification of five different color groups (e.g., bla\ nco, or white; trigueño, or wheat colored; and negro, or black) that represented me\ aning- fully different groups based on color in the local community. One hundre\ d individuals, one-fourth drawn from each of four neighborhoods in Guayama, were recruited to participate in the study. Based on their observation o\ f each participant’s appearance, interviewers assigned them to one of the fi\ ve color groups. Additionally, a narrowband reflectometer was used to objectively determine each participant’s color. Then an automatic blood pressure \ monitor was used to measure each participant’s blood pressure three times dur\ ing an hour-long interview. These researchers found that objectively measured s\ kin color was associated neither with blood pressure nor with which cultural\ ly defined color group a person was assigned to. However, the culturally defined color group was associated with blood pressure, with those labeled blanc\ o or trigueño having statistically lower blood pressure than those labeled\ negro.

In other words, the key factor associated with blood pressure was not on\ e’s actual skin pigmentation (which would reflect genetic influence) but rather how people in the community culturally defined someone’s “race.”\ Rather than finding support for a racial determination of health disparity, t\ his study provides support to the primary competing hypothesis, namely, that havin\ g perceived darker skin subjects individuals “to racial discrimination,\ poverty, and other stressors related to blood pressure” (Gravlee et al. 2005:2191).

Race and Racism In recent years, anthropologists increasingly have dropped the term race, which traditionally was used to refer to biologically distinct groups, from th\ eir lexicon of scientific terms. As the American Anthropological Association affi\ rmed in its 1998 “Statement on ‘Race,’” most physical variation, about 9\ 4 percent, lies within so-called racial groups. Conventional geographic “racial” groupings differ from one another only in about 6 percent of their genes. This means that\ there is greater variation within “racial” groups than between them. In \ neighboring populations, there is much overlapping of genes and their phenotypic (p\ hysical) expressions. Throughout history, whenever different groups have come int\ o con- tact, they have interbred. The continued sharing of genetic materials ha\ s main- tained all of humankind as a single species. Importantly, while anthropo\ logists no longer believe it is empirically valid to use the term race, they nonetheless recognize that racism—bias based on assumed biological differences between populations—is quite real and does significant damage to the health\ of those who are subject to it. 130 Chapter 4 In sum, in the arena of health inequalities, social factors (including \ social inequality) rather than genetic factors tend to be most important. From\ an applied perspective, this means that health inequalities will be limited\ or elimi- nated to the degree that social disparities are limited or eliminated. A\ s succinctly summarized by Krieger (2007:662): “social justice + human rights = \ health equity.” Discussion Questions 1. There has been eye-catching growth in biomedical knowledge and medicine’s expanded capacity to heal in recent decades and yet certain groups have not benefited fully or equitably from these de- velopments; why not? What is the triple burden in seeking health care suffered by ethnic minorities?

2. What is the difference between health disparity and health inequal- ity? Is this a useful differentiation?

3. What did the Institute of Med- icine review of existing studies find with regard to differences in health-care access in the United States? How can we account for these notable differences? 4. What is culturally competent health care? Why is it important?

5. Why is there a need to study the expressions and interconnections of health inequalities across the life span? What are the special risks of children and mothers in today’s world?

6. What did Krieger mean in arguing that social inequality kills? Do you agree?

7. Why have disparities in the health of children in richer and poorer countries around the world been growing in recent years? 131 5 It is no measure of health to be well adjusted to a profoundly sick soci\ ety. —Krishnamurti Introduction and Overview T his chapter focuses on the impact of both the natural environment and th\ e socially constructed environment on human health, placing special emphas\ is on the influence of climate change on the environment, human settlements\ , and health. Further, the chapter discusses the ways in which corporate globalization is playing a crucial role not only in creating health disparities, climate change, and an ecological crisis, but also in contributing to diseases such as c\ ancer and even AIDS. The health of a population related to the environment in which the popul\ a- tion lives has been central to health anthropology for many years. Many \ health anthropologists have attempted to answer this question for specific po\ pulations, and some have attempted to develop general ecological theories of human \ health that apply across local situations. From an epidemiological perspective,\ popula- tion health is rooted in “a stable and productive natural environment\ that: yields assured supplies of food and fresh water; has a relatively constant clim\ ate in which climate-sensitive physical and biological systems do not change for the \ worse; and retains biodiversity (a fundamental source of both present and futu\ re value)” (McMichael and Beaglehole (2003:4–5). This is an ideal that no hum\ an popu- lations experience in full. The reasons they do not, the nature and dete\ rminants of alternative human-environment relations, variations in environment-re\ lated health status within and between ecological zones, and the causes and he\ alth implications of environmental change are the concerns of this chapter. The natural environment refers to the earth’s surface and atmosphere, including biological organisms (of which humans are one species), alon\ g with air, water, soil, and numerous other resources required to sustain life. Due \ to having developed cultures that include technoeconomic, social structural, ideol\ ogical, and attitudinal components, humans are able to survive in a wide diversity of hab- itats, indeed, in most habitats on land surfaces around the planet. They\ do not do so passively by merely adapting to the contingencies in the physical \ conditions around them. Rather, humans are capable of having a profound impact on t\ he natural world, and in this sense the environments humans inhabit are, to\ varying degrees, not really natural in the sense of being pristine and free of h\ uman influ- ence. At the same time, human health is significantly affected by the \ environment Health and the Environment Toward a Healthier World 5 CHAPTER 5 HEALTH AND THE ENVIRONMENT 132 Chapter 5 produced by the daily interaction of natural and sociocultural forces. T\ o take one vitally important and increasingly pressing example—one that, bec\ ause of its significance, we will return to in greater detail later in the chapter\ —the World Health Organization estimates that the earth’s warming climate curren\ tly causes 150,000 deaths and five million illnesses each year. WHO (2014) esti\ mates that approximately 250,000 deaths will be caused by climate change per year b\ etween 2030 and 2050, although it recognizes that this may be an underestimatio\ n. Cli- mate change is contributing to rising rates of malaria, diarrhea (a com\ mon cause of death among children in developing nations), and malnutrition. For i\ nstance, higher temperatures in South Asia have caused elevated rainfall levels a\ nd con- tributed to improved breeding opportunities for mosquitoes. As a result,\ dis- eases spread by mosquitoes, such as dengue fever and malaria, have skyro\ cketed.

Notably, rising temperatures on the planet have a disproportionate impac\ t on poorer nations, those that have through their limited production of indu\ strial pollution or other environmental effects of human technology contributed\ the least to causing global warming. As many scholars have observed, those people who are the most vulnerable to the devastating impact of climate change \ have not been and in the next several decades will not be the ones most responsible for causing it. This responsibility falls upon the shoulders of the affl\ uent, par- ticularly in developed countries but more and more so in developing coun\ tries.

In short, humans both make and are made (and, in the case of disease an\ d death, are unmade) by their environment. As this discussion suggests, the rela\ tionship between human health and the environment is complex, and it has certainl\ y been an arena of debate within health anthropology.

Medical Ecology and Critical Health Anthropology on the Environment Two perspectives within health anthropology—medical ecology and criti\ cal health anthropology, referred to as critical anthropology until recently\ —have especially concerned themselves with human-environment interactions. As \ noted in chapter 1, medical ecology, a biocultural perspective in health anthr\ opol- ogy, views health and disease within an elaborate ecosystem, one that in\ cludes physical, biological, and cultural components (McElroy and Townsend 2014).

The physical, or abiotic, environment includes climate, energy sources, \ and material resources, such as those that can be converted into tools for p\ rocuring food, building shelters, and making clothes to protect people from the natural elements. The biotic environment includes plants and animals that can be con- verted into food, clothing, and even shelter as well as predators, vecto\ rs, and pathogens that can endanger the life of the individual or the group. Fin\ ally, the cultural environment includes technology, social organization, and ideology, all of which serve to sustain health and counteract disease, which is not to say that culture does not play a large role as well in producing illness and deat\ h. According to McElroy and Townsend, changes in any of the components of their model can cause imbalances in the other components (e.g., new \ subsis- tence strategies can lead to exposure to new risks), and a very severe \ imbalance Health and the Environment 133 can generate stress and disease. For example, “a change in climate ma\ y lead to a decrease in food supplies. Erosion of soil may undermine agricultural pr\ oductiv- ity” (McElroy and Townsend 2014:20). Built into the medical ecology model are the following assumptions: (1)\ there are no single causes of disease (e.g., a virus, a vitamin defic\ iency); rather, disease ultimately flows from human-ecosystem imbalances; (2) health and disease develop within the interface of physical, biological, and cultural subsy\ stems; (3) the environment is not only physical habitat but the human-made environm\ ent of villages, towns, and cities; and (4) perceptions of the environment\ are shaped by culture. McElroy and Townsend stress that their ecological-based syst\ ems approach precludes easy explanations of health problems. This is a reaso\ nable assessment; health is a complex phenomenon that is influenced by many factors. While there are points of overlap between medical ecology and critical h\ ealth anthropology in their respective approaches to health and the environmen\ t, there are some notable differences in emphasis as well. Both of these perspect\ ives in health anthropology adopted a version of a biocultural approach that see\ s health and disease as products of the continuous interaction of human biology a\ nd human ways of life and social organization. Both perspectives also overl\ ap with a multidisciplinary approach that first emerged within anthropology call\ ed political ecology, which incorporates political economy but goes beyond examining the relationship of social inequality to health to also consider the impacts\ of social inequality on the environment and, through human interactions with the e\ nvi- ronment, on human health. Contributors to political ecology come from many fields, including sociol- ogy, anthropology, political economy, and geography (Foster et al. 2010; Rob- bins 2012). One scholar provides a succinct overview of the basic premi\ ses of political ecology in his assertion that “economy is a matter of ecolo\ gy: it has to do with the production and distribution of goods and services in the context of human society and nature” (Parsons 1977: xii). Scholars interested in the political economy and political ecology of he\ alth have considered a wide array of politically and ecologically induced health prob- lems, including malaria, tuberculosis, occupational hazards, and cancer.\ To fully understand the political ecology of health in the contemporary world, it\ is necessary to recognize that “the analysis of illness, work, and the e\ nvironment must consider the connections between these issues and the contradiction\ s of capitalism” (Waitzkin 2000:8); this is the world system in which, i\ n varying ways, almost all people on the planet participate. In assessing the role of the environment in human health, the critical perspective in health anthropology draws on the notion that nature has been affected by human events. In other words, the political economy of speci\ fic socio- cultural systems and the world system generally has profoundly shaped th\ e actual physical reality of nature. This approach differs notably from the common view of nature as an autonomous reality that operates in terms of its own pri\ nciples separate from human society, a perspective that is reflected in the se\ paration of “natural history” and “human history” into two different and\ largely separate fields of study but also is seen, more mundanely, in Western ideas abo\ ut getting 134 Chapter 5 back to nature or escaping to nature as refreshment from life in a human\ -made environment. The critical perspective, in contrast, attempts to consider\ “the rela- tion of people to their environment in all its complexity” (Turshen \ 1989:48) and to treat political economy and political ecology as inseparable. Crosby (1986), who uses the term “ecological imperialism” to lab\ el the biological expansion of European life forms (including European peoples\ , their plants, animals, parasites, and pathogens) into all corners of the glob\ e, has con- tributed an important concept for the exploration of the impact of capit\ alist political economy on “nature.” He asserts that this impact involve\ s “a condition of continual disruption: of plowed fields, razed forests, overgrazed p\ astures, and burned prairies, of deserted villages and expanding cities, of humans, a\ nimals, plants, and microlife that have evolved separately suddenly coming into \ intimate contact” (Crosby 1986:291–92). Crosby argues that the ability of\ earlier civili- zations—such as the Sumerians and, much later, Europeans—to conquer indige- nous peoples often had more to do with the fact that they had exposed th\ e latter to a multiplicity of alien diseases than with technological and military\ superiority.

For example, shortly after the First English Fleet arrived in the harbor\ of Sydney, Australia, in 1788, smallpox spread like wildfire both up and down the\ coast and inland among the aboriginal peoples, eventually affecting even residents\ in the remote outback of New South Wales, Victoria, and South Australia.

Health and the Environment in the Past Ancient populations developed fitness to resist environmental threats,\ including climatic ones, periods of food shortage, microbial parasites, and predat\ ors, par- ticularly during the Paleolithic era. Most skeletal remains from the Mes\ olithic (10,000 to 8,000 years BP) and the Upper Paleolithic (40,000 to 10,00\ 0 years BP) eras depict vigorous adults who were relatively free from organic d\ iseases.

People in indigenous societies have reportedly enjoyed cleaner environme\ nts and better health than the majority of people in agrarian civilizations (Co\ hen 1989).

Even today, indigenous people exhibit a scarcity of cancers, cardiovascu\ lar dis- eases, and other degenerative diseases, although researchers often have observed that few people live long enough to contract them, in large part because\ they are vulnerable to parasites, predators, poisonous snakes, accidents, war\ fare, and unexpected harsh climatic conditions that may cause periods of food and \ water shortage or otherwise lead to illness and death. All human societies encroach on and modify the natural environment and have created environmental crises of greater or lesser degree throughout\ their long evolution (Bodley 2012). Foragers contributed to the creation of \ grass- lands, pastoralists overgrazed their lands, and peasants caused deforest\ ation.

Each of these levels of social and technological complexity in human soc\ ial evolution probably contributed to the extinction of certain species. Whi\ le there is a tendency in Western society to romanticize indigenous peoples, such\ as pre-Columbian Native Americans, various species, such as indigenous smal\ l horses, camels, and large game animals in North America disappeared afte\ r the arrival of the first humans in the Americas, perhaps in small or large\ part because Health and the Environment 135 of overhunting. Environmental degradation was one of the principal facto\ rs con- tributing to the demise of the Anasazi (“the ancient ones,” as they are referred to by contemporary southwestern Native Americans) horticultural villages o\ f Chaco Canyon in western New Mexico, the chiefdom societies of Easter Island, a\ nd the Norse settlements in Greenland (Diamond 2005). The emergence of social mechanisms for harnessing large amounts of energ\ y from the environment contributed to the emergence of what Ruyle (1977:6\ 23) has called “predatory ruling classes.” In addition to the role of \ class conflict in contributing to the demise of the earliest state societies (e.g., ancie\ nt Sumer, Egypt, and Rome), as Hughes (1996:29) observes, “their failure to \ maintain a harmonious balance with nature” was a significant factor in their d\ emise. In the New World, environmental devastation created by the classic lowland Maya\ n civ- ilization contributed to a yellow fever epidemic that may have played a \ significant role in the collapse of the Mayan state structure and unifying instituti\ ons. The dangers of ecological self-destruction that plagued ancient state so\ ci- eties became even more pronounced with the advent of industrial capitali\ sm beginning around 1800, and it has been growing ever greater with the pas\ sage of time. In contrast to the smaller-scale environmental modifications \ resulting from the intervention of indigenous societies, global capitalism, with i\ ts tread- mill of production and consumption, introduces a new array of industrial\ and chemical pollutants that disrupt the natural environment and have devastating effects on human health. The Industrial Revolution allowed for the harne\ ssing of nonrenewable fossil fuels, namely, coal, petroleum, and natural gas, and\ humans came to rely increasingly on machine power rather than the energy derive\ d from humans and animals. In order to meet the needs of the capitalist system for functionally hea\ lthy workers, the development of water supplies, sanitation, and agricultural\ practices dramatically improved health conditions and longevity worldwide, but these benefits were unevenly distributed: some societies benefited far mor\ e than others, and within societies some social classes profited disproportionately. \ Conversely, capitalists often ignored the health of their workers if they had access\ to a surplus labor pool and could increase profits by ignoring the physical environ\ ment of the workplace, the pace of the work itself, and the housing and living condi\ tions of the workers. One consequence is the significantly substandard housing found among the poor and working people of a highly marginalized country such \ as Haiti, as seen in figure 5.1. Within the context of the global economy or the capitalist world system,\ any effort to create a healthy global community must come to grips with what\ has been called “the productivist ethic,” a belief that continual econ\ omic expansion is necessary, socially beneficial, and natural, as summarized in folk \ sayings such as “you can’t stop progress.” Closely tied to the productivist ethic is a “culture of consumption” that assumes that humans have insatiable material nee\ ds and live in an environment with endless resources. The productivist ethic, w\ hich is part of the ideology that rationalizes the capitalist mode of production, histori- cally helped drive many of the key social changes that despoiled and continue to despoil the ecologically fragile biosphere while channeling an increasin\ gly large 136 Chapter 5 share of the planet’s limited resources to the privileged few at the \ expense of the masses of people. The global economy has been transforming more and more of the natural environment—including water, forests, beaches, and pla\ nts—into private commodities to be purchased and sold on the market.

Health and the Environment Today The fossil fuel–based technologies that make up industrialization bro\ ught about sweeping environment-reshaping changes, including the growth and polluti\ on of heavily populated urban centers. These changes have had a profound im\ pact on human health. During the twentieth century and continuing in the pres\ ent century, the world has witnessed the emergence of teeming metropolitan a\ reas such as Mexico City, São Paulo, Mumbai (Bombay), Beijing, and Los A\ ngeles, places that environmental scientists call unhealthy “heat islands”\ because of the elevated temperatures their technology and population densities prod\ uce.

Rapid industrialization and technological innovation, including changes \ in transportation and telecommunications, are part of a process that has come to increasingly be referred to as “globalization” or, perhaps more ap\ propriately, “corporate globalization.” A global energy-intensive food producti\ on system, the ever-increasing adoption of motor vehicles and air-conditioning syst\ ems, oversized houses, a myriad of consumer items for the affluent, the inc\ reasing use of air transport for business and pleasure, and other “developmen\ ts” act to strain a fragile ecosystem and ultimately threaten human health. Environ\ mental degradation, as a result, has become a primary public health issue internationally in the contemporary world.

FIGURE 5.1 Poor-quality housing in Cité Soleil, Haiti, reflects the overall poverty of the coun- try. Photo by Merrill Singer. Health and the Environment 137 In their drive for profits, private multinational corporations in the \ West and state corporations in state capitalist societies such as China have crea\ ted not only a global factory but also a new global ecosystem that has resulted in th\ e burn- ing of fossil fuels, motor vehicle pollution, acid rain, toxic chemical \ and nuclear radioactive waste, desertification, defoliation, ozone depletion, and \ greenhouse gases. The last of these, which include chlorofluorocarbons, methane (largely from vast cattle breeding facilities), and carbon dioxide (a direct pr\ oduct of fossil fuels) emitted by motor vehicles, airplanes, ships, and coal- or oil-fi\ red electric generators, have been contributing to ozone depletion and global warming\ .

Carbon dioxide acts like the glass covering of a greenhouse in that it a\ llows heat from the sun to pass through to the earth’s surface while preventing \ much of it from escaping from the planet. Depletion of Natural Resources and Environmental Degradation While to a greater or lesser extent all human societies have historicall\ y encroached upon the natural environment, global capitalism has done so at a much mo\ re pronounced level. In essence, capitalism lacks a concept of sufficienc\ y, of indi- viduals having enough, and demands perpetual economic growth. It operates with the assumption that natural resources are infinite, when in reali\ ty many of them are finite. Capitalism contributes to the depletion of natural resources and environmental degradation, including climate change. While in their thor\ ough and critical analysis of capitalism Marx and Engels did not focus on eco\ logical issues, they were certainly cognizant of the dialectical relationship be\ tween socio- cultural systems and the natural environment. In The Condition of the Working Class in England, Engels (1969; original 1845) described the devastating impact of industrialization on the natural environment. Marx notes numerous exa\ mples of capitalist pollution: industrial chemical waste-product; machine tool manu- facturing iron filings; flax, silk, wool, and cotton washes in the t\ extile industry; rags and discarded clothing; and human excreta in the Thames River in Lo\ ndon (Merchant 2005:146). In essence, global capitalism has created an ecol\ ogical disruption or a “metabolic rift” between society and nature that i\ s “alienating us from the material-natural conditions of our existence and from succee\ ding generations” (Foster et al. 2010:7). Capitalism has been reliant on what Moore (2015:155) terms the “Four Cheaps,” namely cheapened raw materia\ ls, cheap coal, cheap iron, and cheap steel, all of which exist in limited supply.\ Researchers at the Stockholm Resilience Center identify nine “planeta\ ry boundaries” that are essential to maintaining a global ecosystem in w\ hich humanity can survive and thrive safely: (1) climate change, which is on the verge of reaching a tipping point; (2) ocean acidification, also on the ve\ rge of reaching a tipping point; (3) stratospheric ozone depletion, also close to a ti\ pping point; (4) disruption of natural nitrogen and phosphorus cycles; (5) human \ pressure on global freshwater availability; (6) conversion of forests, wetlands\ , and other vegetation types to agricultural lands; (7) biodiversity loss; (8) a\ tmospheric aero- sol loading; and (9) toxic chemical pollution (Rockström et  al. 2009). These 138 Chapter 5 boundaries constitute the “safe operating space for humanity with resp\ ect to the Earth system” but exceeding them would “push the Earth outside\ the stable environmental state of the Holocene, with consequences that are detrimen\ tal or even catastrophic for large parts of the world” (Rockström et \ al. 2009:472).

For climate change, the boundary is 350 ppm of CO 2 in the atmosphere, but this boundary has been surpassed at over 406 ppm of CO 2 and continues to rise because serious mitigation efforts have not been put in place, despite the fact that the Kyoto Protocol was passed in 1997. Despite the ongoing Limits to Growth discussion since the 1970s, governments, corporations, the World Bank, and even the United Nations, as evidenced by its 2012 Conference o\ n Sustainable Development in Rio de Janeiro, are committed to ongoing eco- nomic growth. The development of capitalism expanded the metabolic rift from Europe to\ a global scale of colonialism, imperialism, and corporate globalization \ (Foster et al. 2010:78). Foster provides a long list of “warning signs” signaling the envi- ronmental unsustainability of the capitalist world system, which we summarize in condensed form: •There is virtual certainty that the conventionally critical threshold of 2°C will be crossed in the near future.

•Various studies suggest that with each 1°C increase in global temperature, rice, wheat, and corn yields could drop 10 percent.

•With the world approaching peak oil production, a global crisis and mount- ing resource wars appear to be likely (J. Foster 2009:254–255).

•Global freshwater supplies are diminishing due to the drawing down of aquifers in many locations.

•Two-thirds of the global fish stocks are being depleted.

•Species extinction is at the highest level that it has been in sixty-fi\ ve million years.

•The National Academy of Sciences in the United States released a study in 2002 that indicated that humanity had exceeded the earth’s regenerative capacity in 1980 and by 1999 exceeded it by as much as 20 percent.

•Just as various earlier civilizations and societies have experienced eco\ logical collapse, the capitalist world system faces a similar fate.

Capitalist production has played a central role in a dramatic increase in greenhouse gas emissions as well the creation of a global water crisis. \ As for the first of these developments, the Working Group I component of the 2013–2014 Intergovernmental Panel on Climate Change Fifth Assessment reports the following grim scenario regarding the increase of greenhouse\ gas emissions:

The atmospheric concentrations of carbon dioxide, methane, and nitrous oxide have increased to levels unprecedented in at least the last 800,000 years. Carbon dioxide concentrations have increased by 40% since pre-industrial times,\ primar- ily from fossil fuel emissions and secondarily from net land use change \ emissions.

The ocean has absorbed about 30% of the emitted anthropogenic carbon diox - ide, causing ocean acidification. (Alexander et al. 2013:11) Health and the Environment 139 Whereas only 8 percent of freshwater supplies are utilized for domestic \ use, industry consumes 22 percent of the world’s water and irrigation agri\ culture uses 70 percent (Parr 2013:65). In contrast to a global average water footp\ rint of 1,243 cubic meters per capita per year, the per capita annual footprint of China is 702 cubic meters, with only 7 percent of Chinese water consumption co\ ming from offshore. The water footprint of somebody living in the United Stat\ es is 2,483 cubic meters per year, with 19 percent of that consumption coming \ from outside the country. Meanwhile, in Kenya the average per capita water fo\ otprint per year is just 714 cubic meters, with 10 percent coming from outside t\ he country (Parr 2013:65–86). In addition to wide discrepancies of wat\ er use vary- ing from country to country, there is tremendous class variation in the \ access to freshwater, varying from households that have swimming pools and large l\ awns to people who have limited access to water, particularly clean water. Capitalism and Climate Change Marx’s metabolic analysis can be extended to an examination of global\ climate change involving the linkage of three dimensions: (1) the impact of ca\ pitalism on the global carbon cycle; (2) the Jevons Paradox, in which technologica\ l improve- ments in energy efficiency lead not to decreased but to increased util\ ization of natural resources, and thereby contribute to environmental degradation; \ and (3) the role of capitalism in the destruction of carbon sinks (Foster et \ al. 2010:122).

As is evident from the imperilled list of planetary boundaries, climate \ change is not happening in a vacuum but is growing at a time of multiple and ot\ her anthropogenic ecocrises, some of which, like ocean acidification and s\ tratospheric ozone depletion, are verging on their own respective tipping points. The 2013 Intergovernmental Panel on Climate Change Working Group 1 report projects a rise in global temperature anywhere from 0.4°C to 2\ .6°C by 2046–2065 and from 0.3°C to 4.8°C by 2081–2100, depending on\ what strate- gies humanity takes to mitigate anthropogenic climate change. The World \ Bank (2014) and Price Waterhouse Coopers (2012), hardly radical organizations, reports indicate that the world is presently heading to 4°C or more o\ f warming this century. This global average could mean around 6°C of warming ov\ er land, and perhaps 7–8°C in far northerly latitudes, mind-boggling possib\ ilities to say the least. The National Aeronautical and Space Administration (NASA) reports that\ most of the warming of earth since the 1880s has occurred since the 1970s, with the twenty warmest years having occurred since 1981. Sixteen of the seve\ nteen warmest years on record have occurred since 2001, with 2016 being the wa\ rmest year on record (NASA 2017). Global warming and associated climatic events are a direct effect of an \ increase of greenhouse gas emissions since the Industrial Revolution, wh\ ich kicked off reliance on fossil fuels, initially coal but later petroleum \ and natural gas. Reportedly 556 billion metric tons of CO 2 emissions have been added to the atmosphere since 1750 as a result of fossil fuel consumption and \ land cover change due to increased agricultural production and deforestation. While 140 Chapter 5 climate scientists have debated for a long time whether recent climate c\ hange is primarily a natural phenomenon rather than an anthropogenic one, the \ vast majority of them now agree that it is has been largely created by the em\ ission of various greenhouse gases, particularly carbon dioxide, nitrous oxide, and meth- ane. In one survey, research found that 97.4 percent of the climatologis\ ts and 82 percent of the earth scientists in their sample maintain that human-r\ elated activities are a significant factor in increasing global temperatures \ (Doran and Zimmerman 2009). Despite the existence of many climate denialists or sk\ eptics, particularly in the United States and Australia, they argue that the “\ debate on the authenticity of global warming and role played by human activity is \ largely non-existent among those who understand the nuances and scientific bas\ es of long-term climate processes” (Doran and Zimmerman 2009:23). Atmospheric alone CO 2 has increased from 280 ppm at the time of the Industrial Revolution to 406 ppm in early 2017 (NASA 2017). Whereas du\ ring the 1990s acceleration of CO 2 emissions stood about 1.1 percent per annum, since 2000 the acceleration of CO 2 emissions stood at about 3 percent per annum (more than 2 ppm per year; Rogner et al. 2007). China in particular has become the factory of the world, a place where labor costs are much cheaper than developed countries. According to Malm\ (2016:329), “between 2000 and 2006, 55 percent of the global growth of CO 2 emissions happened there: in 2007, the figure stood at two-thirds.” An increasing percentage of China’s emissions are “export emissions” generate\ d in the process of largely exporting manufactured products to developed countries in Nor\ th America, Europe, and Australia, which do not generally count “import \ emis- sions” into their totals of emissions for which they are responsible.\ Since China joined the World Trade Organization in 2001, thus ending remaining barri\ ers to foreign investment and ownership, China’s export emissions increased from a third during 1990–2002 to nearly half during 2002–2008 (Malm 20\ 16:331). Multinational corporations and state and joint-venture companies in post-revolutionary societies, particularly China, have created a global factory and a new global ecosystem that includes industrial and motor vehicle pollut\ ion, toxic and radioactive wastes, deforestation, desertification, and climate ch\ ange. As a result of its emphasis on ever-expanding production, global capitalism h\ as been having adverse impacts upon large sections of much of humanity and a fra\ gile ecosystem. It has been heavily reliant on fossil fuels, which prompted L\ ewis Mumford (1934) to refer to the world system as a form of “carboniferous” cap- italism. The “industrial-fossil revolution” or “fossil capitalism” relied first upon coal, then oil, and finally natural gas, including coal seam gas. Infectious Diseases in a Globalizing World One of the consequences of corporate globalization has been the emergenc\ e of new infectious diseases and the rapid spread of infectious diseases (ne\ w and old) to previously uninfected populations. The discovery of new pathogens, so\ me of which are already widespread by the time they are recognized as a thr\ eat to human health, is now occurring at a swift pace. Approximately three n\ ew Health and the Environment 141 human infectious diseases are identified every two years, and a new pa\ thogen is reported in the health literature weekly. New diseases in human communit\ ies commonly have their origin in nonhuman animal species (and hence are ca\ lled zoonotic diseases). This process of cross-species infection involving h\ umans has been going on at least since the earliest domestication of animals, and \ it con- tinues to occur today. HIV/AIDS, for example, transferred to humans from\ chimpanzee populations (perhaps as long as a century ago), but the disease did not come to human attention until it spread around the world as a result\ of the global movement of people as tourists, on business, as refugees, as armi\ es on the move, and so forth. Severe acute respiratory syndrome (SARS) is an\ other global pandemic that had its origin in nonhuman animals and later spread\ to and adapted to living in human bodies (as a result of mutation and natu\ ral selection). The possible role of corporate globalization in the spread of infectious\ disease is illustrated by the influenza pandemic that began in April 2\ 009. This zoonotic disease developed in pigs, and the initial epicenter of the out\ break among humans was in a part of Mexico that is home to the massive Smithfi\ eld Foods hog production center, which supplies approximately one million an\ i- mals annually to the world food market. Smithfield, a global corporati\ on, is the world’s largest pork processor and hog producer, with revenues that e\ xceeded $11 billion in fiscal 2010. Industrial farm animal production (known as IFAP) centers, like Smithfield’s operation in Veracruz, Mexico, have been\ found to produce more than livestock. They also generate vast quantities of anima\ l waste that are too large, concentrated, and toxic to be converted into reusabl\ e manure.

The Pew Charitable Trusts and Johns Hopkins Bloomberg School of Public Health have reported that livestock centers like Smithfield are a grav\ e potential source of land and water pollution with toxic and potentially infectious\ animal waste products. Among the prominent concerns explicitly raised by these \ institu- tions is whether large-scale corporate livestock production creates a ri\ sk environ- ment that fosters the emergence of novel viruses such as H1N1 that could\ lead to human infections, sickness, and death.

The Impact of Climate Change on Health Although the global burden of disease due to climate change remains rela\ tively small compared to the impacts on health resulting from poverty, poor san\ itation, and tobacco consumption, climate change over the course of the present cen- tury, particularly under a more or less business-as-usual scenario, will\ result in increasing adverse impacts upon health, particularly among the poor and \ people living in regions relatively close to the equator. The 2014 United Natio\ ns Inter- governmental Panel on Climate Change (IPCC) synthesis report states th\ at there was a 0.85°C (1.35°F) rise in global temperature over the period\ 1880–2012 and a 0.19 meter rise in sea levels over the period 1901–2010. While this may not sound particularly serious, ongoing economic development, coupled with the increasing demands of an ever-growing population—which, in part, is a\ response to the conditions of poverty that push people in particularly developing\ countries 142 Chapter 5 to have more children in order to have enough laborers to meet their sub\ sistence needs—further aggravates the problem. In addition to the general warming of the planet as discussed earlier, c\ limate change has resulted in the melting of icecaps and glaciers around the gl\ obe.

Forty percent of the surface of the Arctic icecap has retreated during t\ he past several decades; glaciers in the Himalayas, Andes, high African mountain\ s, the North American Rockies, and sub-Antarctic island mountains have been rap\ idly retreating; much of the tundra of Arctic areas has been melting and rele\ asing a growing level of methane gas into the atmosphere; and portions of the An\ tarctic icecap also have been breaking up. Because of climate change, plants and\ animals are moving into regions closer to the poles because these regions are be\ coming warmer. Animals, such as polar bears, are in danger of extinction due to\ the con- traction of the Arctic ice pack and a reduction of the animals, such as \ seals, upon which they feed. Coral reef damage is occurring all over the world, including in the Greater Barrier Reef off the coast of Australia. Climate change is already having serious impacts on human, animal, and plant life around the world. South Pacific islanders in particular fac\ e a threat to their traditional horticultural lifestyle because of rising sea levels t\ hat inundate their fields and water supplies and threaten to submerge their islands\ . The Inuit of Arctic Canada and Alaska are experiencing a contraction of the polar \ bear populations that they have traditionally hunted, and they are unable to \ access seals because the icepack is freezing later than it once did. Andean peoples face the possibility of the eradication of their way of life as glaciers from which they have drawn water for themselves, their fields, and their animals retre\ at. Peoples living in coastal areas around the world face the possibility of increas\ ed flooding and hurricanes because of the rise and warming of the oceans. A growing \ number of prominent climate scientists now believe that global warming contribu\ ted to the devastating effects of hurricanes Katrina, Rita, and Wilma in 2005. \ Among these is Judith Curry of Georgia Tech University, whose research has sho\ wn that an ever-greater percentage of hurricanes are of the most intense kind, i\ n no small part, she believes, because global warming is increasing the temperature\ of the world’s oceans. According to Curry, Hurricane Katrina was “the 9/1\ 1 of global warming” (quoted in Lang 2006:4). Further, many climate scientists contend that the droughts that people i\ n parts of sub-Saharan Africa and Australia have been facing are related t\ o climate change warming as well. Moreover, climate change appears to be the prima\ ry impetus behind the spread of infectious diseases to environments north a\ nd south of the equator and heat waves that threaten the lives and health o\ f vulner- able populations, such as the elderly and the sick. Warmer temperatures have contributed to the spread of mosquito-borne diseases, such as malaria, in South Africa, the highlands of Kenya and T\ anzania where it was previously nonexistent, to the higher elevations in the And\ es of Colombia; disease-carrying mosquitoes that once lived at altitudes no hi\ gher than 3,200 feet have now appeared at the 7,200-foot level (Berger 2000)\ . While climate change is not the only factor involved, today it is estimated th\ at there are 300 million to 500 million cases of malaria in Africa each year, res\ ulting in Health and the Environment 143 between 1.5 million and 2.7 million deaths, more than 90 percent occurri\ ng among children under five years of age. Global warming also has been i\ mplicated in the resurgence of various other epidemics, including cholera in Latin America in 1991, pneumonic plague in India in 1994, and the outbreak of a hanta \ virus epidemic in the U.S. Southwest also in 1994. Even in temperate zones, cl\ imate change may contribute to greater frequency of diseases such as tick-born\ e viral encephalitis, which occurs in parts of Western Europe, Scandinavia, and \ Russia, and Lyme disease (McMichael 2001:302). Additionally, climate change may endanger people’s health and even th\ eir lives through heat exhaustion, as was the case during the summer of 2003\ in Western Europe and Russia in 2010. The estimated mortality of some 70,00\ 0 people in the case of the heat waves in 2003 in Western Europe and 55,000 people in Russia was associated not only with the high temperatures but \ also with the fact that nighttime low temperatures have been rising nearly tw\ ice as fast as daytime temperatures (McMichael 2017). The lingering nighttime warmth deprived people of normal relief from blistering daytime temperatures an\ d of the opportunity to recuperate from heat stress. Air pollution linked to longer, warmer summers particularly affects those suffering from respiratory pro\ blems, such as asthma. The heat waves in Western Europe in 2003 and Russia in 2\ 010 contributed to 30 percent declines in grain harvests, accompanied by inc\ reases in food prices, food shortages, and nutritional deficiencies among the\ poor in grain-importing countries (McMichael 2017). Elderly people with higher blood pressure and/or heart disease along with possible obesity are particular\ ly likely to die or require medical attention during heat waves. Given the health consequences of climate change, we can speak of diseases of climate change. These would not necessarily be new diseases, although they might be, but would include any “tropical” disease (e.g., malaria\ and dengue fever) that spreads to new places and peoples because of global warming\ as well as diseases linked to poor nutrition due to desertification of pastora\ l areas or flooding of agricultural areas. Merrill Singer (2009, 2010b) developed the term ecosyndemic to label the role of anthropogenic changes in the environment that increase the frequ\ ency of adverse disease interactions and, as a result, increase the health burde\ n of affected populations. Ecosyndemics are likely to concentrate among the poor and o\ ther marginal communities, who are least able to obtain adequate nutrition, s\ anita- tion, shelter, low-stress life experiences, and preventive and curative \ health care.

Climate change is disrupting natural ecosystems and contributing to the \ geo- graphic diffusion of disease-causing viruses, bacteria, fungi, and other\ pathogens.

Diseases that have increased in range because of global warming include \ malaria, dengue, Rift Valley fever, West Nile disease, Chikungunya fever, yellow \ fever, hanta virus, Seoul virus, and Zika. Increased planetary warming is also \ a factor in the spread of disease-bearing rodents (as well as other disease vectors\ ) like those responsible for the outbreak of hanta virus in the U.S. Southwest in 199\ 4 and pneumatic plague in India the following year. Furthermore, water-borne diseases such as cholera are spreading because of ever-warmer oceans. 144 Chapter 5 There is growing recognition that the time is overdue for anthropologist\ s, including health anthropologists, and other social scientists to begin e\ xamining the impact of global warming on human populations, including their healt\ h.

As McMichael (2003:15) aptly observes, “This topic is likely to bec\ ome a major theme in population health research, social policy development and advoc\ acy during this first decade of the twenty-first century.” While arch\ aeologist Brian Fagan (1999:76) is correct in his assertion that “global warming is\ nothing new for humanity,” the magnitude of the global warming or climate change \ that the planet has been experiencing over the past several decades and that is p\ redicted will continue for decades to come, even if it is checked by monumental p\ reemp- tive measures, is on a magnitude never experienced before by humanity. Climate change constitutes one of the most important issues of the twen- ty-first century, along with the growing gap between the affluent an\ d the poor within most nation-states and between nation-states, thanks to corporate\ global- ization and ongoing conflicts in many parts of the world. The latter i\ n part can be attributed to various states, led by the United States but also inclu\ ding the United Kingdom and Australia, doing the bidding of multinational corpora\ tions in what Klare (2002) calls the “resource wars.” We have called f\ or the develop- ment of a critical health anthropology of climate change warming that re\ cognizes its relationship to the treadmill of capitalist production (Baer and Si\ nger 2009).

The four authors of this textbook maintain that, ultimately, climate change or global warming is a problem that is part and parcel of global capitalism\ with its drive for profits that results in a pattern of ever-increasing pro\ duction and consumption. There is much debate on how to adapt to and mitigate climate change, ranging from turning to alternative energy sources (such as wind, solar\ , biomass, and even nuclear, which many argue would be an utter ecological and heal\ th disaster) to planting trees and developing environmentally friendly tec\ hnology and energy-saving devices. Many of these proposals would be steps in the\ right direction, but others, particularly schemes such as carbon trading, carb\ on off- setting, geoengineering, growing biofuels on land that could produce foo\ d, or eliminating forested areas to clear land for biofuel crops, are dubious.\ Conversely, there would be a significant drop in climate change if the majority of people in the developed world and the affluent in the developing world were to o\ pt to live simpler lifestyles by restricting the use of motor vehicles; relying mor\ e on mass transit, bikes, and their feet for transportation; and consuming less. Ultimately, as we state in our concluding chapter, an authentic program of mitigation t\ o reverse the trend toward climate change will require transcendence of global cap\ italism. Global climate change is only the exposed “tip of [a] broader global- sustainability iceberg” that includes a litany of environmental degra\ dations that are now “converging rapidly in a manner not previously experienced”\ (Spratt and Sutton 2008:xi). All of these threats (e.g., acid rain, air pollut\ ion), which are connected to the transformation of the earth’s biomass into an ever-grow- ing human population, have vital implications for a host of human diseas\ es and other threats to health (e.g., exposure to toxins). Even more signifi\ cant than the number of health-related degradations that are occurring is the issue of eco- crises interaction. Rather than the various environmental calamities we face and Health and the Environment 145 their respective configurations of health indicators being stand-alone \ threats to human well-being—which is the conventional but limited outlook that l\ eads to fragmented and even competitive mitigation efforts—adverse human impa\ cts on the environment intersect and the resulting interaction significantly exacerbates the overall human (as well as other animal and plant) health consequences; these interacting ecocrises create the potential for catastrophic outcomes (Singer 2009). Although all countries and regions of the world are suffering the ill ef\ fects of climate change as well as other forms of pollution and environmental \ degra- dation, poor countries and poor people in all countries, namely those wh\ o are generally least responsible for pushing the earth system toward even mor\ e dras- tic changes, are the victims disproportionately dealing with the consequ\ ences.

While the injustice of the existing global economy is recognized by main\ stream global organizations such as the United Nations in the form of the Susta\ inable Development Goals and the World Bank in its call to eradicate extreme po\ verty, such bodies generally do not call for a drastic redistribution of the wealth and resources of humanity, a stance that is imperative for addressing the he\ alth rav- ages of climate change and other environmental problems for particularly\ the poor. As we argue in the final chapter, achieving a healthier world po\ pulation will require an alternative world system based upon social justice, envi\ ronmental sustainability, and a safe climate.

Other Environmental Impacts on Health Chlorofluorocarbons also play an important role in ozone depletion, wh\ ich has allowed a significant increase in the amount of ultraviolet light \ striking the earth’s surface, especially in portions of the Southern Hemisphere ne\ arest the pole, namely, southern Australia, New Zealand, Argentina, and Chile. Whi\ le skin cancers are a well-known health consequence of ozone depletion—and ra\ tes of these diseases have been rising steadily (e.g., skin cancers account fo\ r around 80 percent of all new cancers diagnosed in Australia each year)—increas\ ed ultraviolet radiation at ground level also can lead to mutations, especially among v\ iruses, whose only protection from the air is a thin layer of protein. As a reflection of the underlying productivist ethic that led to their\ creation, national indices of growth and development, such as the gross domestic p\ roduct, count only the production of goods and services that are sold in the mar\ ketplace (i.e., commodities) but do not take into account the impacts of their \ production, such as environmental degradation. While the emergence of global capitalism has ensured plentiful (if far from equitably distributed) food resourc\ es (including nutritionally dubious ones), modern sanitation, and biomedicine for som\ e, these material benefits have often been obtained at the expense of the masse\ s of people in developing nations and the working class in the developed world. Even\ the privileged few in the developed world face the danger of ecocide. Two categories of health risks are posed by corporate globalization: (1\ ) pri- mary health risks stemming from changes in the social and natural environment and (2) more specific forms of health risks (McMichael and Beagleho\ le 2003).

The former includes the following: (1) growing socioeconomic dispariti\ es both 146 Chapter 5 within and between nation-states, a topic that we discussed in the previ\ ous chapter; (2) the fragmentation and weakening of labor unions as multin\ ational corporations attain greater influence over governments around the world and thereby endanger occupational health in their insatiable drive for profi\ ts; (3) the depletion of the biodiversity of plants and animals, as reflected \ in vast acres devoted to a single plant, such as wheat or corn, and the destruction of\ the hab- itats that support many species; and (4) the spread of “invasive”\ species, most notably humans themselves, resulting from imbalances in biodiversity and\ the dispersal of persistent organic pollutants. The latter include the follo\ wing: (1) the spread of tobacco-related diseases and dietary diseases resulting fr\ om food consumption patterns shaped by marketing campaigns intended to convince \ people to eat nutritionally dubious foods that are high in carbohydrates, starches, and fat but low in protein and vitamin content; (2) the proliferation \ of motor vehicles, including more recently in developing societies, such as China\ ; (3) the rise of obesity in urban populations where most people follow a relative\ ly seden- tary lifestyle; (4) the expansion of international drug trafficking \ related in part to demoralization among socioeconomically disadvantaged populations, includ\ ing youth, searching for an escape from the alienation of modern life; (5)\ the spread of infectious diseases due to increased global travel; and (6) the inc\ reasing prev- alence of depression and other mental ailments in aging and socially iso\ lated people, particularly in urban areas. Although public health measures and secondarily biomedicine have done much, although by no means enough, to counter the threat of infectious d\ iseases, there has been growing concern in recent years about what have been term\ ed “emerging diseases.” There exist four types of emerging infectious\ diseases: (1) newly described conditions that have been discovered or recognized only \ within the past few decades (e.g., HIV and SARS, or severe acute respiratory s\ yndrome); (2) expansion of a familiar disease into a new region or habitat (wha\ t have been called “reemerging diseases,” such as malaria or Zika); (3) mar\ ked increase in the local incidence of a disease, as seen with Ebola; and (4) increased severity or duration of an older disease or its increased resistance to previousl\ y effective treatment (e.g., tuberculosis). The spread of emerging diseases appear\ s to be a consequence of several factors. These include major environmental changes such as deforestation and reforestation, intensification of agriculture, da\ m construc- tion and irrigation, mining, and housing and road construction; the incr\ easing concentration of people in overcrowded and densely packed cities (parti\ cularly in the developing world); the global movement of people due to migration, \ busi- ness, and tourism; and the development of pathogen resistance to overuse\ d and misused antibiotics.

Water and Globalization In terms of health and illness, particularly with reference to infectiou\ s diseases, whether of the older variety or the new emerging variety, access to clea\ n freshwa- ter is crucial, perhaps more than most of us in the developed world think, because, as it is available at the turn of a faucet handle in so many places, we \ often take it Health and the Environment 147 for granted. Although water covers more than 70 percent of the world’\ s surface, particularly in the form of oceans, less than 1 percent of the water on \ the planet is available for human consumption, thus making it a precious natural resource that has increasingly become commodified within the context of corpora\ te glo- balization. A growing number of anthropologists have addressed this issu\ e, as reflected in the book Globalization, Water, and Health. In this volume, Linda and Scott Whiteford (2005:9–10) delineate four categories of diseas\ es related to water: (1) waterborne diseases, such as cholera, typhoid, and hepatiti\ s, emanating from the ingestion of water containing pathogenic organisms; (2) water\ -washed diseases resulting from a lack of water for washing or personal hygiene;\ (3) water- based diseases, such as schistosomiasis, resulting from exposure to nonh\ uman parasitic hosts in activities such as bathing, swimming, or washing clot\ hes; and (4) water-related diseases, such as dengue, West Nile fever, malaria, \ and yellow fever in which humans come into contact with water that an insect vector\ uses as a breeding ground. Many of these diseases could be prevented if peopl\ e had access to clean water for drinking, cooking, washing, and recreational p\ urposes as well as access to sanitary living conditions and adequate nutrition. \ Whereas for eons access to water, particularly in indigenous societies, was view\ ed as a human right, with the spread of global capitalism, water is being redefi\ ned as a commodity. In today’s world, increasing competition for clean water h\ as been contributing to a tremendous increase in the number of deaths and diseas\ es that could be easily avoided if world resources were not so inequitably distr\ ibuted.

Thus, we can speak of a political ecology of water that “can be and should be more explicitly linked to human health and well-being” (Whiteford et  al. 2016:233).

The political ecology of water concerns itself with the utilization, mea\ nings, dis- tribution, cost, and ultimately of water as a crucial resource for suste\ nance, but also one that is highly contested on the part of a multiplicity of actor\ s, ranging from powerful multinational corporations and governments to ordinary people who find themselves on the margins of a capitalist world system. Clean water supplies increasingly are being threatened by climate change\ , mining, agriculture (which uses about 69 percent of the world’s fres\ hwater supply), deforestation of mountainous woodlands, and urban sprawl. With respect to the last issue, in his contribution to the volume mentioned p\ revi- ously, Carl Kendall (2005) discusses the impact of Lima, Peru’s rap\ id growth on the availability of fresh clean water in an arid coastal plain. The R\ imac River, Lima’s primary water source, has become heavily polluted with heavy m\ etals from nearby mines, high levels of nitrates and other organic compounds, \ and untreated sewage. Furthermore, the Lima aquifer has become polluted with\ fecal matter and other pollutants. Lima residents experience high rates \ of diar- rhea that are intimately related to a shortage of water and contaminatio\ n of their water supply. Water insecurity also constitutes a serious challenge in remote Alaska communities, where many households lack running water and sewer services\ (Eichelberger 2016). High water tables, permafrost, seasonal floodin\ g, limited economic resources, and poverty all compromise reliable access to water.\ In some villages more than 10 percent of households lack access to piped water, a grim 148 Chapter 5 reality that contributes to high rates of invasive pneumococcal infectio\ n. As the Whitefords so aptly observe, Protecting the physical environment and human health must be part of a d\ eeper change in societal values. For anthropology and other social sciences to\ partici- pate in this transformation through methodologically rigorous, theoretic\ ally in- formed, and socially relevant research is the biggest challenge. (S. Wh\ iteford and L. Whiteford 2005:265) Fortunately, ordinary people in various parts of the world, such as wome\ n in South Africa—a country where theoretically access to water is enshrin\ ed in the country’s constitution as a human right—have been campaigning for \ “water cit- izenship” that will ensure access to a resource essential for sustena\ nce and health (Bulled 2016).

The Political Ecology of Cancer Cancer is an ancient disease that was little understood in the past, and its prev- alence prior to the nineteenth century is not known. Whereas many infect\ ious diseases have been on the decline, although AIDS and some other emerging\ dis- eases are notable exceptions, cancer rates rose dramatically during the \ twentieth century and have continued to do so into the present century. Cancer is \ largely a disease of development rather than underdevelopment, as indicated by the\ World Health Organization’s estimate that about one-half of cancers occur i\ n the most industrialized fifth of the world’s population (Proctor 1995:2). \ Within specific nation-states, cancer rates vary in terms of the type of cancer, regiona\ lly, between the sexes, and among ethnic and religious groups. Cancer etiology is a frequently debated topic, one about which scientist\ s find themselves adopting diametrically opposing interpretations. Some argue that cancer is caused primarily by an array of environmental factors, others \ that it is related to lifestyle, and still others that it is related to stress, emotions, hereditary factors (referred to as “genetic susceptibility”), aging, and ho\ rmonal distur- bances. Very likely, each of these factors plays some role in cancer etiology, and which ones are more significant varies greatly from person to person a\ nd by type of cancer. Nevertheless, each of these theories ultimately has political\ implications that have contributed to the “cancer wars,” which include disagree\ ments about the most effective way to treat it, ranging from the conventional approa\ ches of radiation, chemotherapy, and surgery to a wide array of alternative ther\ apies. Several epidemiologists and public health scholars have sought to addres\ s the narrow reductionism they find inherent in prominent approaches to \ disease etiology generally and cancer etiology specifically by adopting a mult\ icausal model that shows that a huge number of phenomena go together to produce \ illnesses. Within medical health anthropology, some proponents of the bi\ ocul- tural approach identify six factors contributing to disease: genetics, n\ utrition, the environment, psychogenesis, iatrogenic forces, and infection (Brown et  al.

1996). However, the multicausal model tends to lead to political inacti\ on because “prevention policy has to attack all possible causes at once—\ a strategy Health and the Environment 149 that could stretch available resources far beyond their capacity and end\ up by devoting only pittance to each” (Tesh 1988:62). Furthermore, the mu\ lticausal model fails to come to grips with the issue of primacy—that is, whether certain factors, particularly political economic and political ecological ones, \ play a more important role in disease etiology (Turshen 1989). There exists considerable evidence that a disproportionate incidence of \ cancer occurs among members of lower-income groups and workers exposed t\ o industrial carcinogens, although there are some exceptions. For instance\ , higher breast cancer rates among professional women in affluent communities, \ such as San Francisco and the Upper West Side of Manhattan, may be related in pa\ rt to the fact that many of these women postpone bearing children until later \ in their lives. Theories that emphasize political economic and environmental factors in cancer etiology have tended to receive short shrift in health policy and cancer pre- vention circles, such as in the National Cancer Institute and the Americ\ an Cancer Society, largely because addressing them would require major social stru\ ctural changes that ultimately would require transcending the existing global e\ conomy. Samuel Epstein in The Politics of Cancer (1978) documents links between industrial pollutants and rising cancer rates. He estimates that 70 to 9\ 0 percent of cancers are induced by exposure to environmental and occupational exp\ osure to carcinogens. More recently, Epstein (2005), on the basis of data fr\ om the Northeast, argued that breast cancer, as well as other cancers, has been\ associated with living near hazardous waste sites. In light of these findings, Epstein (1979, 2005) argues that industr\ y has adopted an elaborate strategy that seeks to exonerate itself from its contribution to cancer etiology, including blaming the victims by postulating the exi\ stence of “hypersusceptible workers,” who allegedly are more prone to con\ tract can- cer, and moving hazardous chemical facilities to developing nations when\ labor unions and environmental groups have managed to convince politicians to \ pass environmental legislation. Drawing upon the pioneering research of Epstein on environmental factors\ contributing to cancer etiology, various critical health anthropologists have come to view cancer as an “environmental and economic disorder rooted in m\ aterial practices” around the globe (Burke and Mathews 2017:179). Unfortuna\ tely, while biomedicine has made tremendous strides in comprehending the biolo\ gy of cancer cell development, it along with scientific, corporate, and g\ overnmental bodies continues to downplay the environmental causes of cancer. The pre\ vail- ing approach in these circles is to place personal responsibility for cancer on the patients themselves, an approach consistent with neoliberalism (Karakasidou 2015).

Cancer in the Community Anthropologist Martha Balshem (1993) was intimately immersed in the de\ bate between the lifestyle and environmental theories of cancer etiology when\ she worked as a health educator at the Fox Chase Cancer Center in Philadelph\ ia, a role in which she found herself feeling increasingly uncomfortable. Her \ highly 150 Chapter 5 engaging and readable book Cancer in the Community explores “cancer control” in a European American working-class inner-city neighborhood in Philadelphia that Balshem calls Tannertown (pseudonym). The Fox Chase Cancer Center\ focuses on the prevention of suffering, namely, lowering cancer morbidit\ y and mortality, by encouraging its clients to change their lifestyles, includ\ ing ceasing smoking, following certain dietary regimens, and having regular cancer s\ creen- ing examinations. Expressive of this approach, with funding from the Nat\ ional Cancer Institute, the Fox Chase Cancer Center initiated Project CAN-DO, \ a five-year cancer education campaign between 1983 and 1988 in Tannertow\ n.

According to Balshem, Tannertowners tend to reject the assertion that th\ eir high cancer rates were a result of their lifestyles but instead viewed air po\ llution ema- nating in large part, but not entirely, from nearby chemical plants, occ\ upational exposures in the plants, motor vehicle pollution, and the chemical adult\ eration of their food and water as the primary sources of cancer. Balshem (1993:75\ ) found that respondents expressed frustration and fear in response to their per\ ceived arrogance of the scientists and a discourse that while acknowledging env\ iron- mental factors in disease etiology, asserts that people can prevent canc\ er through lifestyle changes. In twenty-five one-on-one interviews and eight focus groups, Balshem f\ ound that while her respondents tended to view cancer as resulting from both \ lifestyle and environmental factors, they believed that making lifestyle changes w\ ould be a useless preventive measure in lowering cancer risk. The health educato\ rs at the center followed the official health prevention paradigm that stresses \ individual responsibility for good health. Balshem (1993) maintains that the skep\ ticism that Tannertowners expressed about the views of scientific experts and\ health educators on cancer constitutes a manifestation of the loss of control t\ hat they feel over their daily lives. Interestingly, she goes on to argue “that the community critique of medical science mirrors that of critical studies in medical anthropol- ogy” (Balshem 1993:89). This is only partly true in that Tannertown\ ers often assume that God or fate plays a role in whether they develop cancer. In \ coping with their sense of powerlessness, they—particularly the men—had c\ ome to view themselves as being tough and determined to beat the odds. Perhaps if sc\ ientists, who undoubtedly Tannertowners view as privileged members of society, were more willing to join forces with them in challenging corporate power, of\ which the former had some sense, they might not feel so powerless as a collect\ ivity and have to resort to individualistic coping mechanisms rooted in U.S. cultu\ re.

Cancer and Industry In contrast to Balshem’s cultural interpretive account of Tannertowne\ rs’ view on cancer etiology, David Michaels (1988) conducted a provocative poli\ tical economic analysis of corporate policies toward bladder cancer in the U.S\ . dye industry—one that appears in a special issue of Medical Anthropology Quarterly on “Health and Industry” that was guest edited by Ida Susser, a well-known criti- cal health anthropologist. Despite the fact that European scientists dem\ onstrated in the early twentieth century that beta-naphthylamine and benzidine, two Health and the Environment 151 chemicals commonly utilized in dye production, are deadly bladder carcinogens, there is reason to believe that the U.S. dye industry has systematically\ ignored and suppressed these and later findings concerning the link between th\ ese two chemicals and bladder cancer (Michaels 1988).

China’s Cancer Villages China’s massive industrial expansion, with annual economic growth rat\ es of 9–10 percent at its zenith, has been supported by its heavy export of a wide \ array of products, ranging from automobiles to electronic goods to clothing. Coal\ , of which China has massive supplies, provides for 68.7 percent of China’\ s total energy consumption, but also results in carbon dioxide emissions and sul\ fur diox- ide emissions, the latter which causes acid rain. Modernization has cont\ ributed to China having sixteen of the twenty most polluted cities in the world \ (Gerth 2010:185). Under Deng Xiaoping’s policies, the costs of economic modern- ization and massive urbanization were tremendous, including environmental degradation, industrial and motor vehicle pollution, increasing greenhou\ se gas emissions, lack of adequate safety standards, growing socioeconomic ineq\ uality, and social conflicts. Increasing inequality in China contradicts revol\ utionary egalitarian ideals and has contributed to an increase of social struggle\ s in both urban and rural areas. In early 2013 the Chinese government finally acknowledged the existence of “cancer villages,” pockets of high incidence associated with po\ llution. Unfor- tunately, serious epidemiological studies of these cancer villages remai\ n spotty.

Nevertheless, cancer villages have been linked primarily with the chemic\ al indus- try and secondarily with paper factories, resource extraction and proces\ sing, and heavy metals emanating from these activities. Given the lack of conventi\ onal epidemiological studies, villagers have taken matters into their own han\ ds by engaging in popular epidemiology, in which they seek to find an association between industrial pollution and deleterious health consequences. Conven\ tional scientists, the Environmental Protection Bureau at the county level, and\ the Chinese Center for Disease Control and Protection at the national level \ generally dismiss these studies. Anna Lora-Wainwright (2016), a health anthropologist, conducted ethnic\ research on Baoma (a pseudonym), a “cancer village” in 2004–2\ 005 and for shorter periods thereafter. Baoma village is situated in a hilly area si\ x kilometers from Langzhong city in the northeast of the Sichuan Basin. Under moderni\ za- tion, chemicals have been introduced into village farming practices, suc\ h as the use of pesticides and fertilizers, and very likely have contributed to r\ ising rates of cancer, along with polluted water streams that carry heavy metals and\ toxic chemicals. Indeed, cancer communities tend to be situated along China’\ s major rivers. Nevertheless, many villagers attribute cancer to repressed anger\ and anx- iety induced by close relatives who may blame a woman who does not produ\ ce a son, for instance. In a local epidemiological study of fifty familie\ s residing in Baoma during 2003–2007, eleven of them reported cancer, six among mal\ es and five among females. Cancer treatment may be unavailable to many househ\ olds 152 Chapter 5 due to its high costs. According to the village secretary in 2004, payments for cancer treatment may come to as high as 20,000 yuan, an extremely high c\ ost given that the typical annual income was estimated to be about 1,500 yua\ n. Furthermore, the CDC has difficulty assessing disease rates at the loc\ al level, meaning that “villagers are trapped between their own village-level evidence and the scale at which the government operates” (Lora-Wainwright and\ Chen 2016:403). As a consequence of serious government response to pollution\ -related cancer cases, residents in some cancer villages have resorted to violent\ protests, petitions, and lawsuits. In the view of Lora-Wainwright and Chen (2016:\ 411– 12), while the “official recognition of the existence of cancer vi\ llages may serve as an opening for civil society forces concerned with the environment to ra\ ise their complaints or to legitimize their activities,” it may also constitute\ an attempt by the government to “reclaim the terms of debate on cancer villages and to silence further protests by suggesting” that it is addressing the problem.

Anthropological Examinations of Cancer Treatment Numerous health anthropologists, often in collaboration with research fr\ om other disciplines, particularly ones in the health sciences, have conduc\ ted ethno- graphic and survey research on cancer treatment. Instead of focusing on \ envi- ronmental factors in cancer etiology, cancer conferences in North Americ\ a often pinpoint lifestyle factors, such as smoking and diet, as being the prima\ ry factors contributing to cancer (Bell and Ristovski-Slijepcevic 2015). While indeed life- style may constitute a contributing factor in cancer etiology, cancer co\ nferences tend to neglect how alienation in the workplace or social life may lead \ individ- uals, particularly from working- and lower-class backgrounds, to adopt c\ ertain lifestyle habits as means for coping with their marginal status in the larger soci- ety. Other studies have pinpointed the differential access to cancer tre\ atment in various developed societies, ranging from a welfare capitalist society such as Denmark where cancer treatment falls under the umbrella of a national he\ alth place with extensive services (Høybye and Tjørnhøj-Thomsen 201\ 4) and other Scandinavian countries (Andersen et  al. 2014), to the United States, a laggard in terms of cancer treatment for working- and low-income people, particu\ larly ones from various ethnic minorities (Luque et al. 2010, 2011; Joseph and Dohan 2012). Some cancer patients, particularly women who have or have had br\ east cancer, have engaged in activism in the United States and served as a ke\ y force in the passage of the Breast Cancer and Environmental Research Act of 20\ 08 (Anglin 2016).

Nuclear Reactors and Health Radiation is highly dangerous to living tissue. The uranium split in a n\ uclear reactor or in spent fuel can damage a cell, including the DNA that carri\ es the cell’s genetic information. Damaged DNA in an egg or sperm can be pas\ sed onto successive generations. The nuclear industry mines, mills, and distribut\ es ura- nium and leaves radioactive waste products resulting from nuclear fiss\ ion in the process of creating electricity. Despite nuclear plant mishaps at Three \ Mile Island Health and the Environment 153 in Pennsylvania in the 1970s and Chernobyl in the Ukraine, the nuclear e\ nergy industry managed to reposition itself as constituting a green energy sou\ rce that does not emit greenhouse gas emissions and thus contribute to climate ch\ ange, in contrast to fossil fuels. The nuclear industry defines itself as a \ key component in the economic growth of many developed societies and growing economies\ , particularly China, India, and Russia. Furthermore, some notable natural scien- tists, such as James Lovelock and Tim Flannery, and James Hansen, one of\ the most prominent climate scientists in the world and a high-profile clim\ ate activist, have come out in favor of using nuclear energy as a method for mitigating green- house gas emissions. However, nuclear energy is not a renewable resource. Aside from the issues of the dangers posed by nuclear waste materials, the construction of nuclear plants creates significant greenhouse gas emissions and pollution (Ca\ ldicott 2006). Fears of the risks of nuclear power reactors came to fruition with the Fukushima nuclear disaster in the wake of the earthquake and the tsunami\ on March 11, 2011. The mainstream and alternative media asked various anthr\ o- pologists to comment on this event. Despite the fact that the nuclear di\ saster would have serious impacts on health, as Johnston (2011:3) observes, “\ what is the most disturbing for Japanese citizens, residents, and to a much less\ er degree for those downwind, is that—despite the acknowledgments that the wors\ t has happened, that emissions continue to persist, that there is no viable pl\ an for the safe control and cleanup—the average citizen still struggles to acces\ s current and meaningful information that might inform proactive action that reduc\ es exposure and minimizes risk.” The Japanese government restricted the shipping of foods, farm animals, and fish from many prefectures (Eddy and Sase\ 2015).

Highly radioactive waters discharged into the Pacific Ocean. Unlike th\ e nuclear disasters at Three Mile Island and Chernobyl, the Fukushima disaster was caused by a natural event and tells us that nuclear disasters can have multiple\ origins, including possibly terrorism.

Unconventional Natural Gas Extraction and Health Natural gas extraction, known by the term fracking or hydraulic fracturing, is an unconventional natural gas extraction process surrounded by much controv\ ersy for both environmental and health reasons (Kaden and Rosie 2015). In r\ eality, fracking is one step in unconventional gas extraction (UGE), which inc\ ludes “pad construction, drill setup, drilling, hydraulic fracturing (or fracking), gas processing, well decommissioning, and land restoration” (Paulson and\ Tinney 2015:1–2). Unconventional gas extraction results in air pollution du\ ring well production, numerous truck trips to create a pad, setup of the drilling \ equip- ment, transporting workers and supplies to the pad, drilling and frackin\ g the well, removing waste from the pad, and transporting methane from the sit\ e either by trucks or in pipelines. Methane and volatile organic compounds (VOCs\ ) releases can occur during exploration and upon storage of methane in var\ ious storage sites in the form of leakage. Sand used to open the fractures in\ the shale allowing the gas to escape can aerolize, thus presenting a serious healt\ h hazard 154 Chapter 5 to miners and workers at the pad. Other forms of pollution resulting fro\ m the extraction process are benzene and ozone; water may become contaminated \ in various ways. In Pennsylvania and Texas there have been “clear, well-\ documented episodes of migration of natural gas into the drinking water supply” \ (Paulson and Tinney 2015:12). Ultimately, the UGE process releases methane, a very p\ owerful greenhouse gas, into the atmosphere, and natural gas derived from the pr\ ocess contributes CO 2 to the atmosphere. The Impact of Private Motor Vehicles on Health Motor vehicles, with their internal combustion engines, embody the socia\ l structural contradictions of the world system. The world now has over a \ billion automobiles along with other private motor vehicles, particularly recrea\ tional or camping vehicles and motorcycles, and this number continues to rise r\ apidly as many developing countries such as China, India, Indonesia, and Brazil but certainly others, imitate developed societies in their adoption of the c\ ar culture.

Motor vehicles impact patterns of production and consumption, settlement, traf- fic congestion, mass transportation, the environment, and environmenta\ l health.

They constitute a major contributor to air and noise pollutions, greenho\ use gas emissions, and ultimately climate change as well as fatalities, injuries\ , stress, social isolation, and obesity. The private automobile constitutes the ultimate commodity for an increas\ ing number of people around the world, indeed a killer commodity or death machine.

The automobile industry and a massive road network are pivotal to the hi\ story of global capitalism (Flink 1988). Along with industrial pollution, motor\ vehicles have transformed many cities around the world into ecological disaster a\ reas accompanied by a wide array of health problems. Car-related injuries, de\ aths, and disease are ultimately proportionally inflicted by the relatively affl\ uent upon the poor, many of whom cannot afford to purchase an automobile. Due to weake\ r environmental protection laws in developing societies, their cities in p\ articular experience high levels of pollution from a wide array of motor vehicles,\ including not only private automobiles and motorcycles but also buses and trucks (\ Bohren 2009). Motor vehicle emissions consist of sulfur oxides, nitrogen oxides, carbo\ n monoxide, hydrocarbon, volatile organic compounds, toxic metals, lead pa\ rticles and particulate matter, and carbon dioxide, which contribute to acid rai\ n, climate change, and cardiovascular, pulmonary, and respiratory diseases. Benzopy\ rene, a by-product of gasoline exhaust, is a carcinogenic chemical that become\ s sus- pended in urban air. Aside from the amount of CO 2 emissions that motor vehi- cles produce, their manufacture and the construction of highways also re\ sult in CO 2 emissions (Robbins et al. 2010:136).

Automobile accidents reportedly result in more than 1.24 million deaths \ per annum worldwide and an estimated twenty million to fifty million injur\ ies, of which 91 percent occur in low- and middle-income or developing societies\ where safety standards are not as developed as in high-income countries (WHO \ 2013).

One study concludes that “motorized violence” takes the forms of o\ besity, dia- betes, and cardiovascular disease, ailments that are in large part a con\ sequence Health and the Environment 155 of diminished active travel that has contributed to a global obesity epidemic (Woodcock and Alfred 2008). In essence, heavy reliance on cars as a mo\ de of transportation results in less exercise through walking and cycling and \ thus to obesity and various related diseases. Despite the existence of massive corporate support for the ongoing use of private motor vehicles, there have been counterhegemonic efforts, partic\ ularly in developed societies, to resist the automobilization of society by emp\ hasizing the need for people to rely on other forms of mobility, including public\ trans- portation, cycling, and walking. Even walking to a train station or a bu\ s stop has health benefits in the form of modest exercise. Some urban planners an\ d public transportation advocates are calling for pedestrian or carless cities.

The Political Ecology of AIDS: Assessing a Contemporary Syndemic Acquired immune deficiency syndrome (AIDS) has emerged as one of the\ most devastating diseases in human history. While there has been a decline in\ the level of AIDS-related deaths in recent years, the World Health Organization (\ 2017c) estimated that 1.1 million people died of the disease in 2015, indicatin\ g that the epidemic is far from over. Caused by a contagious virus known as the human immunodeficiency virus (HIV), the disease has spread rapidly to all \ human pop- ulations in all corners of the planet. The actual origins of HIV are not precisely known, but it appears to have evolved from similar viruses, called simia\ n immu- nodeficiency viruses (SIVs), that infect monkey and ape species. Gen\ etically, HIV is most similar to the SIV found among chimpanzees, our closest rela\ tive in the animal kingdom. Current thinking is that SIV underwent a mutation\ that allowed it to infect human hosts sometime in the late nineteenth or earl\ y twen- tieth century. This kind of “species jump” is a not-uncommon occur\ rence with infectious pathogens in nature. The political ecological context for thi\ s transition was the expansion of human settlements into previously forested areas in Africa, associated with the population explosion, deforestation, expanded agricu\ lture, and more rapid transportation produced by colonialism and neocolonial ec\ on- omies. Expansion into previously unsettled areas in tropical zones—wh\ ere the concentration of microscopic life is highest on the planet—appears to have been the source of a number of the emerging infections of recent decades. Whatever its point of origin, HIV found the human body, especially components of the \ blood system, a habitable environment; human sexual contact and pregnancy init\ ially and other routes of transmission eventually (e.g., injection drug use a\ nd blood transfusion) all proved to be effective mechanisms for moving between h\ osts and led to its rapid spread within and across populations. The global count of people living with HIV/AIDS infection reached forty \ million by the end of 2004; millions more had already succumbed to the d\ isease.

Although HIV/AIDS is now found everywhere, it is unequally distributed a\ mong the populations and subpopulations of the world. One way of understandin\ g the unequal spread of this disease is by examining the number of people livi\ ng with HIV/AIDS disease along a geographic continuum. At one end of the continu\ um is sub-Saharan Africa, which remains the region hardest hit by the disea\ se. Near 156 Chapter 5 the opposite end of the continuum falls North America. While life expect\ ancy is increasing in the United States and Europe despite the presence of HIV/A\ IDS, in many Third World countries the disease is significantly shortening \ how long people live on average. How can we understand the significant disparit\ ies found in HIV/AIDS prevalence and impact among countries of the world? A starting point in answering this question is to examine disparities in\ HIV/ AIDS in the United States because of the great differences in the social\ condi- tions that exist for different populations in the country. Wealth is hig\ hly concen- trated in the United States, with the wealthiest 2 or 3 percent of the p\ opulation controlling 40 percent of the nation’s wealth and the poorest 20 perc\ ent of the population controlling hardly any wealth at all. These disparities in we\ alth are matched, as discussed in chapter 4, by great disparities in health. Moreover, these inequalities of wealth and health reflect important contrasts ac\ ross ethnic populations. HIV/AIDS is more prevalent—and significantly so—among African Am\ eri- cans than any other ethnic population in the country, a pattern that hol\ ds across age and gender subgroups. Importantly, while the number of deaths among \ whites living with HIV/AIDS has steadily fallen, among African Americans the pi\ cture is more complicated. In 2014, approximately 3,500 African Americans died\ of AIDS-related conditions, accounting for 53 percent of total deaths attri\ buted to the disease that year, although African Americans make up about 12.3 per\ cent of the total population of the United States. Notably, HIV diagnoses among \ African American gay and bisexual men increased by 22 percent between 2005 and 2\ 014, although this rate has since declined (Centers for Disease Control and Prevention 2017). In other words, while compared to some other parts of the world \ the HIV/ AIDS prevalence is low in the United States, HIV-related sickness and de\ ath are heavily concentrated in the African American sector of the U.S. populati\ on. More- over, there is a distinct parallel between disparities in the distributi\ on of HIV/ AIDS between the wealthier and poorer nations of the world and between t\ he wealthier and poorer populations within the United States. This parallel suggests that HIV/AIDS does not exist in isolation from ot\ her diseases or from the social and political economic environment that shap\ es a pop- ulation’s health, access to food and shelter, and availability of med\ ical treatment.

To help frame an understanding of these interrelationships, health anthr\ opol- ogists introduced the concept of syndemic in the early 1990s (Singer and Clair 2003). While biomedical understanding and practice traditionally have b\ een characterized by the tendency to isolate, study, and treat diseases as i\ f they were distinct entities that existed separately from other diseases and indepe\ ndently of the social contexts in which they emerge, a syndemic model directs atten\ tion to social and biological interconnections in health as they are shaped and \ influenced by inequalities within society. At its simplest level, the term syndemic refers to two or more epidemics (i.e., notable increases in the rate of specifi\ c diseases in a population) interacting synergistically with each other inside human bodies and contributing, as a result of their interaction, to an excess burden of d\ isease in a population beyond what would otherwise be expected. It refers not only t\ o the temporal or locational co-occurrence of two or more diseases or health prob- lems but also to the health consequences of the biological interactions \ among Health and the Environment 157 copresent diseases, such as between HIV and tuberculosis (TB). HIV-pos\ itive individuals infected with TB, for example, are one hundred times more li\ kely to develop active disease than those who are HIV negative with TB. Simil\ arly, research has shown that individuals coinfected with hepatitis C (HCV) \ and HIV have higher HCV viral loads (i.e., levels of infectious agents in t\ heir bodies) than those infected with only HCV. Beyond the notion of disease clustering in a social location or populati\ on and the biological processes of interaction among diseases, the term “\ syndemic” also points to the critical importance of social conditions in disease interactions and consequences. As Farmer (1999:51–52) has emphasized, “The mo\ st well demonstrated co-factors [for HIV] are social inequalities, which structu\ re not only the contours of the AIDS pandemic but also the nature of outcomes o\ nce an individual is sick with complications of HIV infection.” Living in\ poverty, for example, increases the likelihood of exposure to a range of diseases, in\ cluding HIV. Given the impacts of (1) stress that is associated with poverty, \ unemploy- ment, population density, and exposure to unsafe environments; (2) poo\ r diet (especially early in life); and (3) heightened exposure to human-mad\ e toxins in local environments—which tend to be disproportionately common in l\ ow- er-income areas where populations are more dense and opportunities to es\ cape exposure to toxins are lower (e.g., high concentrations of lead in olde\ r homes and poor heating systems leading to sealed windows and poor ventilation)\ , dis- eases tend to concentrate among impoverished populations. The concentrat\ ion of multiple diseases in one population increases the biological likeliho\ od of dis- ease interaction of various kinds (e.g., gene swapping or “assortmen\ t” among co-occurring pathogens or opportunistic infection by one pathogen becaus\ e of damage done by another) as well as the adoption of behaviors to cope wi\ th and medicate the emotional injuries of oppression and relative deprivation, \ such as abusive drinking and illicit drug use, which damage the human immune sys\ tem.

Additionally, poverty and discrimination place the poor at a disadvantag\ e in terms of access to diagnosis and treatment for HIV as well as ability to adhere to treatment plans because of structurally imposed residential instabili\ ty and the frequency of disruptive economic and social crises in poor families. Racism, for example, is a critical social condition that appears to cont\ ribute to higher levels of HIV risk and infection. In Brazil, for example, while eth- nic-based oppression is denied officially and at the popular level, st\ udies show that “the structures of racism are present in everyday experience”\ (Goldstein 2003:105). Consequently, writing of internalized racism in Brazil, Neus\ a Santos Souza (1983) notes that dark-skinned Brazilians commonly feel inferior\ and ugly because of all of the subtle reminders to which they are subjected \ each day that whiteness equals beauty. Internalized racism, no less than open col\ or-based discrimination, is linked with heightened levels of HIV risk and infecti\ on (Baer et al. 2013). Ultimately, social factors, such as poverty, racism, sexism,\ and mar- ginalization may be of far greater importance in HIV morbidity and mortality between and within countries than the nature of the virus. Poor populati\ ons and populations of color encounter HIV/AIDS not as a single life-threate\ ning disease but as part of a set of interacting diseases and toxic social an\ d biological conditions with a resulting significant toll on their health and well-\ being. 158 Chapter 5 In summary, this chapter discusses the complex relationship between health and environment, delineated in large part by two theoretical perspective\ s in health anthropology, namely medical ecology and critical health anthropo\ logy.

In terms of the present era, it focuses on how the depletion of natural \ resources and environmental degradation, particularly anthropogenic climate change\ , affect the spread of infectious diseases. Finally, the chapter also examines th\ e political ecology of cancer and HIV/AIDS, two pandemics that have spread throughou\ t much of the modern world. Discussion Questions 1. How do medical ecology and critical health anthropology com- pare and contrast in their respec- tive approaches to examining human-environment interactions?

Discuss in particular how critical health anthropology draws upon political ecology of health.

2. What does Alfred Crosby mean in his use of the term “ecological imperialism”? Discuss how indig - enous people in the Americas and Australia were impacted by eco- logical imperialism.

3. Compare and contrast the over - all health status of people in early foraging, horticultural, and agrar - ian state societies. What was the impact of the emergence of capi- talism on workers, particularly in urban settings?

4. Discuss how transcending the nine “planetar y boundaries” identified by Johan Rockström and his col- leagues at the Stockholm Resilience Center endanger both the earth’s ecosystem and ultimately human health. What do John Bellamy Fos- ter and his colleagues mean when they argue that capitalism is in a “metabolic rift” with nature?

5. In what ways do you agree with Foster in his listing of “warning signs” that signal the long-term unsustainability of the capitalist world system? Discuss McMichael and Beaglehole’s two categories of health risks posed by corporate globalization.

6. How has global capitalism contrib- uted to climate change? In what ways might capitalism be reformed to mitigate its present deleterious impact upon climate change, or ultimately may it be necessar y to conceptualize an alternative world system that leads to a safer climate for all human beings?

7. What impacts do epidemiologists and other health scientists envision resulting from climate change in terms of the spread of infectious diseases? Delineate and discuss the four types of “emerging infectious diseases” in the modern world.

Discuss Merrill Singer’s concept of ecosyndemic in elucidating the im- pact of anthropogenic changes in the environment that contributes to negative health outcomes.

8. In what ways is access to clean wa- ter crucial in maintaining global health?

9. Discuss various theories on the eti- ology of cancer. What has been the impact of capitalist industrial and agrarian practices on the spread of cancer, not only in developed soci- eties but also in developing societ- ies such as China? 159 6 Formerly, when religion was strong and science weak, men mistook magic for medicine; now, when science is strong and religion weak, men mistake medicine for magic. —Thomas Szasz, The Second Sin (1973) Introduction and Overview I n chapter 3, we examined conceptions and explanations of health, disease\ , and illness with which people around the world operate. In this chapter,\ we introduce the notion of ethnomedicine in order to demonstrate that all m\ edical systems, be they national guises of biomedicine or indigenous medical sy\ stems or folk medical systems in complex societies, either preindustrial or posti\ ndustrial, are part and parcel of culture and society. We also discuss how various \ anthro- pologists have attempted to categorize medical systems. Finally, we intr\ oduce an evolutionary model of disease and healing systems drawing on the work of\ others that examines how various types of societies ranging from nomadic foragi\ ng to postmodern societies seek to explain the causes of illness as well as th\ e categories healers use to identify and treat sickness. Approaching Ethnomedicine Historically, health anthropologists have devoted considerable attention to the study of medical systems in indigenous or tribal societies, in peasant c\ ommuni- ties, and among subgroups of urbanites in developing nations. Even before the emergence of medical anthropology or health anthropology as a named area\ of specialization within anthropology, ethnographers recorded data about he\ alth beliefs and practices, including healing techniques, in indigenous socie\ ties. Med- ical systems in indigenous societies and peasant communities and among o\ ther ordinary peoples have often been defined within anthropology as “et\ hnomedi- cines.” Charles Hughes (1978:151), a renowned health anthropologist, defined ethnomedicine as “those beliefs and practices relating to disease which are the products of indigenous cultural development and are not explicitly deriv\ ed from the conceptual system of modern medicine.” However, many medical anth\ ro- pologists since Hughes did his seminal work have noted that biomedicine \ also constitutes an ethnomedical system, one that has diffused from Western s\ ocieties to many other societies around the world. An elaborate overview of the p\ urview of ethnomedicine is summarized in table 6.1. Ethnomedicine The Worlds of Treatment and Healing 6 CHAPTER 6 ETHNOMEDICINE 160 Chapter 6 TABLE 6.1 The Purview of Ethnomedicine Domain Concerns Ethnomedicine of the body Body image Relationship between culturally specific images of the ideal body and their relationship to health beliefs and practices Ethnophysiology Cultural conceptions about body structure and function, including internal organs Ethnomedicine of the mind Ethnopsychiatry Culture and recognition of mental illness Culture and expression of mental illness Culture and occurrence of mental illness Ethnopharmacology Focuses on drugs or medicine utilized within specific cultures Source: Adapted from Quinlan (2011).

Ethnopsychiatry or culture psychiatry as a sub-genre of ethnomedicine concerns itself with culture-bound syndromes, such as latah in Indonesia and Malaysia, which refers to highly exaggerated reactions to various stimul\ i, susto in Latin American cultures, which is a response to a frightful experienc\ e, and pibloktoq among the Inuit of the Arctic region, which entails tiredness or con- fusion accompanied by an outburst of culturally inappropriate behavior, \ such as tearing off one’s clothes, frantic running, or rolling in the snow. A\ nthropologists view these conditions as cultural idioms of distress. They serve as cult\ ural vehicles through which to express emotional upset in the form of physical symptom\ s that draw the attention and support of significant others and the broader community.

Within different cultural systems, different body organs may be the focu\ s of these syndromes. In Iran, for example, the heart is a common focus, while in C\ hina the liver, kidneys, or spleen tend to be emphasized. As a result of globalization and enhanced global communication on the internet and in the media, ques\ tions have been raised about the disappearance of culture-bound syndromes, alt\ hough it is increasingly clear that various syndromes that once were regarded \ as cul- ture-bound are more widely dispersed than was originally realized and gl\ obal communication may be a factor in the spread of these conditions. Ethnographers, including those working in the anthropology of religion, \ have long been fascinated by the shaman, a part-time religious healer wh\ o con- tacts the supernatural realm, often by going into a trance, in order to \ alleviate the distresses and diseases of his or her patients. Others have been str\ uck by the role of the modern biomedical physician, a healer with unparalleled tech\ nological resources for measuring, visualizing, and treating disease who still mus\ t deal face- to-face with a nervous patient in need of as much care as cure, such as \ the patient interacting with a podiatrist in figure 6.1. Ethnomedicine 161 In reality, all medical systems constitute ethnomedicines in that they d\ evel- oped from and are embedded in particular sociocultural systems, regardle\ ss of whether they are small-scale or state societies. In this sense, all healers, from sha- mans to cardiovascular surgeons, are ethnohealers, even though the latte\ r have far transcended the boundaries of any single ethnic group or population \ because their orientation to healing is rooted in Western culture (Erickson 200\ 8). Moreover, as Lynn Payer (1988) notes in her highly entertaining and re\ ad- able book Medicine and Culture, biomedicine is shaped by its specific cultural or national setting, as she found to be the case in France, Britain, Germany, and the United States. American biomedicine relies much more on invasive for\ ms of therapy, including cesarean sections, hysterectomies, breast cancer scre\ enings, bypass heart operations, and high dosages of psychotropic drugs, than do\ es biomedicine in the other three countries. British physicians are less co\ ncerned about moderately elevated blood pressure and cholesterol counts than are\ their U.S. counterparts, and German physicians are much less likely to prescri\ be anti- biotics than U.S. physicians. In large part, the latter pattern is becau\ se German biomedicine emphasizes the self-recuperative aspects of the body and has\ long been open to natural healing techniques. German biomedicine, in fact, co\ nsists of two varieties: (1) Schulmedizin, or “school medicine,” which is taught in major medical institutions, such as Humboldt University and the Charité\ , and (2) Naturheilkunde (nature cure), in which biomedical physicians may acquire FIGURE 6.1 Podiatrist examining a diabetic patient’s feet at health program organized by medical anthropologists and public health activists. Photo by Merrill Singer. 162 Chapter 6 training through special workshops and apprenticeships. In contrast to A\ meri- cans and the British, French biomedical practitioners generally take rec\ tal rather than oral temperatures because of the greater accuracy of the former alt\ hough this method can result in rectal bleeding. Finally, whereas American wom\ en tend to prefer breast enlargements, French women tend to prefer breast reduct\ ions. While this chapter focuses on the ethnomedical practices of indigenous p\ eo- ples around the world, it also discusses biomedicine as both a “globa\ l medical system” (i.e., an ethnomedicine that has transcended multiple cultur\ al boundar- ies) and a structured array of somewhat interconnected ethnomedical sub\ systems.

Ethnomedical research involves “the study of how well-being and suffe\ ring are experienced bodily as well as socially; the multivocality [i.e., having \ many voices or, more precisely in this context, having multiple means of expressing \ different kinds of information] of somatic [bodily] communication; and processes o\ f heal- ing (their relative success and limitations) as they are contextualize\ d and directed toward the person, household, community and state, land and cosmos” (\ Nichter 1991:138).

Indigenous and Folk Medicine Systems While the term “primitive medicine” was in use in the early days o\ f anthropo- logical interest in health and healing, the term is problematic for seve\ ral reasons.

In addition to implying a priori (before it is empirically tested) tha\ t indigenous or folk medicine is not effective, it also lumps all nonbiomedical syste\ ms into one box, but in fact there is considerable diversity in such healing systems\ .

Ways of Healing Indigenous societies often incorporate members of the community who func\ tion as a therapeutic management group into the healing process. All of these dimen- sions are exemplified among the Navajo where the singer (as healers a\ re known in the Navajo or Dine tradition) constructs an elaborate sand painting \ depicting the Holy People and chants over the patient in order to reestablish harm\ ony, the loss of which is believed to cause illness. As the singer destroys s\ ections of the sand painting, it is believed that various aspects of the patient\ ’s sickness are eradicated. Traditional medicine, like Navajo healing, often stresses emotional catharsis for the patient and draws the supportive attention of fellow m\ embers of the community to the patient’s illness. At the same time, Navajo h\ ealing has a naturalistic orientation, as is evidenced by its broad pharmacopoeia c\ onsisting of herbs, powders, teas, and animal substances (e.g., powdered insects,\ cow dung, and so on). The Incas of the Andean region practiced trephination\ , which entailed the removal of part of the skull in treating fractures or remov\ ing brain tumors, purportedly in order to release a malevolent spirit. An estimated 25 to 50 percent of the substances in the traditional nonbi\ o- medical pharmacopoeia of indigenous healers have been shown empirically \ to be effective as measured by conventional scientific and biomedical standa\ rds. Other naturalistic techniques found in traditional medicine include herbs, pow\ ders, bone setting, massages, sweat baths, and mineral baths, as well as the s\ uturing Ethnomedicine 163 of wounds with various items, such as sinews among Native American group\ s, thorns among the Masai, and biting mandibles from the heads of termites \ among both Somalis and Brazilian Indians. The Aleut and Inuit people are adept\ sur- geons as a result of a pool of anatomical knowledge that they have devel\ oped from their hunting of sea mammals. The Masai, in turn, operate on absces\ ses of the liver and spleen. Mayan healers in Belize, in a manner similar to\ that of traditional Chinese medicine and Ayurvedic medicine in India, rely upon \ pulsing as a diagnostic technique, accompanied by various indigenous healing pra\ yers (Hatala and Waldram 2017). People sometimes view healers from other cultures or societies as more p\ ow- erful and efficacious than their own healers. For example, the Iraqw o\ f northern Tanzania often seek healers from other ethnic groups, such as the Sukuma\ , the Ihanzu, the coastal Swahili, and ones from Somalia, even if these healer\ s do not speak the Iraqw language. The Iraqw often state that “we believe the \ medicine of other’s peoples to be stronger than our own” (quoted in Rekdal\ 1999:460).

Cross-cultural healing may serve as a means of fostering social connecti\ ons that prevent or reduce interethnic conflict and avoiding local healers who \ may be viewed as capable of malevolent or exploitative acts. Ironically, in dev\ eloped societies, including the United States and Australia, large numbers of p\ eople have come to embrace non-Western medical systems, such as traditional Ch\ inese medicine, Tibetan medicine, and Ayurveda.

Typologies of Healing Systems In their efforts to summarize the broad diversity and range of health be\ liefs and practices found in a wide diversity of sociocultural systems around the world, medical anthropologists have created various typologies of conceptions o\ f disease etiology within medical systems. One scheme, for example, offers a matri\ x of the geographic distribution of various ethnomedical theories of disease caus\ ation depicting that three types of causation beliefs are worldwide: biomedica\ l under- standings, theories of illness due to loss of internal balance within bo\ dy systems, and acceptance that illness can be caused by exposure to someone with an\ “evil eye” (Erickson 2008). We present three alternative ethnomedical typ\ ologies here, although these by no means exhaust the range of schemes that have \ been developed. One of the earliest of these suggested that every medical sys\ tem embraces both a “disease theory system” and a “health-care syst\ em” and, fur- ther, that medical systems include both an ideological component and a s\ ocial structural component (Foster and Anderson 1978). The disease theory system includes ideas about the nature of health and ideas about the causes of \ disease or illness. This typology makes a distinction between personalistic syst\ ems and naturalistic systems. The former view disease as resulting from the acti\ on of a “sensate who may be a supernatural being (a deity or god), a nonhuman being (such as a ghost, ancestor, or evil spirit), or a human being (a witc\ h or sorcerer)” (Foster and Anderson 1978:53). Naturalistic systems, by contrast, view\ disease as emanating from the imbalance of certain inanimate elements in the body, \ such as the male and female principles of yin and yang in Chinese medicine. Pers\ onalistic and naturalistic explanations are not mutually exclusive. The health-care system 164 Chapter 6 refers to the social relationships and interactions between the healers \ and their patients. The healer may be assisted by various assistants and in the ca\ se of com- plex societies may work in an elaborate bureaucratic structure, such as \ a clinic, health maintenance organization, or hospital. Another approach, one based on types of healers within an ethnomedical system, categorizes shamans, mediums, sorcerers, and priests as examples\ of personalistic practitioners, while they group herbalists, chemists, body\ workers, and lay midwives into the category of naturalistic practitioners (Loust\ anunau and Sobo 1997). Herbalists are found in the great majority of societies\ and prescribe or treat patients using medicinal plants but also minerals, as\ is the case in the Madagascar village studied by Harper as described in chapter 2. C\ hem- ists or pharmacists dispense both over-the-counter and prescription drug\ s and in developing countries often give injections. Indeed, in developing cou\ ntries, chemists, without a prescription from a biomedical physician, often disp\ ense both brand name and generic drugs, including what are generally legally \ defined as controlled substances in developed countries. While surgery is a high\ ly presti- gious specialty within biomedicine, various individuals in indigenous an\ d archaic state societies practice or did practice surgery. One common surgical te\ chnique of traditional surgery is trephination. The Incas have already been ment\ ioned as practitioners of this surgical art, but many other types of surgery h\ ave been described in indigenous societies around the world. Bodyworkers are muscu- loskeletal specialists who massage or manipulate the body to alleviate m\ uscular tensions or skeletal misalignments. Finally, lay, or “direct-entry,” midwifery around the world has been the focus of much medical anthropological rese\ arch (Davis-Floyd et  al. 2001). Midwives have generally delivered infants in indige- nous societies and continue to do so, particularly in developing countri\ es but increasingly so in developed societies as well. In reality, specific h\ ealers may be a blend of the various types delineated by Loustanunau and Sobo, such as when humoral doctors act as both chemists and herbalists or healers mix naturalistic and personalistic techniques. Individuals follow various paths in becoming traditional healers. One is\ by “divine selection,” in which the prospective healer has a dream in\ volving the vis- itation of a spiritual guide who reveals that the dreamer has been chose\ n to serve the people in this manner. Individuals who themselves have been healed f\ rom a serious disease commonly are chosen to become traditional healers, thus the term “wounded healer,” which has even been applied as well to many prof\ essional psychologists and psychiatrists in modern and postmodern societies. In a\ ddition, individuals who desire to become healers may undergo an apprenticeship w\ ith an established healer, often a member of one’s kinship group. Allan Young (1976a), a health anthropologist with a strong interest in\ medi- cal knowledge, has developed two separate models that focus on the way m\ edical systems organize knowledge about diseases. In the first of these, he d\ istinguishes between (1) internalizing systems, which focus on physiological explan\ ations and biophysical signs that the healer can detect, indicating the nature \ of disease episodes (such is the case in biomedicine), and (2) externalizing sy\ stems, which stress events outside the sick body. In the latter, the disease-causing \ agents are Ethnomedicine 165 generally animate and even human or at least humanlike, such as a witch \ or a sorcerer. It is the healer’s job to determine what events prompted \ the dis- ease-causing agent to attack the patient, as is the case in Navajo medicine where the singer attempts to restore a balance between the patient and social \ group, natural environment, or the wider cosmos. Young argues that externalizing medical systems tend to develop into internalizing medical systems with \ growing social complexity. In his second model, Young (1976b, 1977) posits two types of systems: \ (1) accumulating medical systems, which consist of accumulated, formalized teach- ings, generally in written form, that are shared with prospective practi\ tioners in training institutions or with colleagues at conferences or in profession\ al associa- tions (e.g., biomedicine, Ayurveda and Unani in South Asia, and Chinese\ medi- cine), and (2) diffusing medical systems, in which practitioners gene\ rally do not share medical knowledge (thus making it rather diffuse or unsystematic) with one another and regard it to be secret (e.g., shamans and magical healers)\ . Finally, using a biocultural or medical ecological perspective, Horacio \ Fab- rega (1997) has developed an elaborate scheme of medical systems on wh\ ich we draw in this chapter and elaborate on in our discussion of medical plura\ lism in the next chapter. Fabrega proposes the abbreviation “SH” to refer \ to a hypothe- sized biological adaptation for sickness and healing (i.e., like the bi\ ological adap- tations that have been made among desert-dwelling animals to allow them \ to live in great heat with limited moisture, species have also adapted to the su\ rvival chal- lenge of sickness with healing behaviors). For example, he maintains th\ at chim- panzees exhibit some basic behaviors, such as the use of leaves to wipe \ themselves and the use of leaf napkins to dab at bleeding wounds, suggesting a preh\ uman SH adaptation, but also observes that chimps exhibit some non-SH respons\ es as well, such as aversion to and exploitation of sick group members. More r\ ecently, it has been discovered that certain species of caterpillars when infecte\ d with various diseases will eat plants that have chemicals that are effective \ against the specific attacking disease agent. Fabrega suggests that many of the SH charac- teristics of chimpanzees existed in early hominid societies and that SH \ became more refined during prehominid stages of human evolution, as is implie\ d by the presence of healed fractures in some Neanderthal remains. He maintains t\ hat patterns of food sharing and reciprocity between the sexes provided a so\ cial con- text for the SH adaptation because the latter also entails cooperative b\ ehavior.

Asserting that “SH constitutes the foundational material for the elab\ oration of medicine as a social institution,” Fabrega (1997:70) argues that th\ e providers of SH (i.e., healers) in early foraging societies were highly insightful individuals who possessed an elaborate knowledge of the social organization of their\ society.

An Evolutionary Model of Disease Theories and Healing Systems Drawing on the work of several health anthropologists, we propose an evo\ lution- ary model of disease theories and healing systems, shown in table 6.2. 166 Chapter 6 TABLE 6.2 An Evolutionary View of Illness Theories and Healing Systems Type of Society Purported Causes of Illness Types of Healers Nomadic foraging Self, ancestors, gods, outsiders Shamans, diviners Village level—simple horticulturalists Same as foragers plus group members as possible agents, simple ethnopathologies Shamans, magico-healers, mediums, herbalists Nomadic pastoralists Same as simple horticulturalists and in some cases imbalances between hot and cold foods Healers, mediums, exorcists, and sometimes religious healers associated with world religions Chiefdoms—sedentary foragers and intensive horticulturalists Same as simple horticulturalists Healers, mediums, herbalists, shamans among sedentary foragers Early state societies Same as above Same as above plus priests Early empires/civilizations Individual behaviors, moral failings, elaborate ethnopathologies, imbalances in body humors Priests, professional physicians, folk and religious healers Modern industrial societies Germs, genes, lifestyles, highly elaborate ethnopathologies Orthodox and heterodox professional physicians, religious and folk healers, diversity of additional healers Postmodern societies Same as above plus emotions interacting with body, return to humor theories in some medical subsystems Same as above plus movement to integrate orthodox and heterodox modalities Health, Illness, and Medicine in Family-Level Foraging Societies Family-level foraging societies, such as Australian Aborigines and the I\ nuit of the Arctic region, tend to have shamanic healers who often employ idiosy\ n- cratic techniques that they try to conceal from other practitioners. The\ juncture of medicine and religion is particularly exemplified in the role of th\ e shaman, who has been depicted by anthropologists, scholars of comparative religi\ on, transpersonal psychologists, and New Agers as the prototypical traditional healer.

The word “shaman” is a term associated with the Tungus, a reindeer\ -herding group in Siberia who use it to label a part-time religious healer who is\ in direct contact with the supernatural realm. Fascination with shamans harkens ba\ ck to Russian scientific expeditions into Siberia in the seventeenth and eig\ hteenth Ethnomedicine 167 centuries. Other terms used to refer to this practitioner include “ma\ gician,” “medicine person,” and “witch doctor.” The shaman has one or\ more spirit guides at his or her command, may be male or female, and is often “ca\ lled” by spirit familiars through dreams or visions. Shamans often are considered\ eccentric and have been described by various ethnographers as moody, highly introv\ erted, highly perceptive and intelligent, and intimately aware of their sociocu\ ltural system. Shamans among the Chuckee people of Siberia often are homosexual\ s, and those in some societies may be transvestites. There are several ways\ by which individuals become shamans, including inheriting the position from a par\ ent, receiving a “call” from a spirit, recovering from a serious illnes\ s, or possessing outstanding abilities, such as being an excellent hunter, having psychic\ abilities, or being insightful. In essence, the shaman is a complex figure with a multiplicity of roles. As a religious intermediary, the shaman visits the supernatural realm to peti\ tion favors, including the curing of diseases; as a diviner, the shaman locates wild \ game for hunting or lost objects or diagnoses illness; as a judge, the shaman det\ ermines when people have violated rules, such as having eaten taboo food or expr\ essed anger inappropriately; and as an entertainer, the shaman carries out ela\ borate performances, including dance, sleight of hand, ventriloquism, shaking t\ he cer- emonial tent by pulling a series of strings and thus simulating the entr\ ance of the spirits, and wearing colorful costumes. As a healer and psychotherap\ ist, the shaman uses both naturalistic and supernaturalistic techniques. Ritual h\ ealing techniques include soul retrieval, removal of disease-causing objects, e\ xorcism, confession, and sacrifice. Michael Winkelman (2000) argues that shamanistic practices induce extraor- dinary experiences and healing by producing integrative processes in the\ limbic system or paleomammalian brain. He further asserts that shamanism evolve\ d during the course of human history as a practice for symbolically and ps\ ychophys- iologically enhancing well-being, both in the shaman and in patients. In\ entering into an altered state of consciousness, the shaman—unlike the Haitian\ houngan described in chapter 2—is not possessed by the spirit guides but rath\ er controls them in order to achieve many tasks, including healing, dream interpreta\ tion, divination, clairvoyance, handling of fire, communications with spirit\ s of the dead, recovery of lost souls, mediation between the gods and mortals, an\ d pro- tection against spirits and malevolent practitioners. The shaman’s cu\ ring cere- mony functions as an important social event that provides a means of int\ egrating the patient into the immediate social group but also contributes to the \ social and psychic unity of the larger collectivity. Winkelman (2000:276) maintains that shamanistic practices serve as a “set of sophisticated traditions for managing self, emotions, and c\ on- sciousness.” He views shamanism primarily as a phenomenon of foraging\ or hunting-and-gathering societies but maintains that aspects of classical shamanism persist in later or more complex societies. Altered states of consciousn\ ess induced by shamanic mimetic rituals, such as chanting, singing, drumming, dancin\ g, and other repetitive behaviors, may activate the human relaxation respon\ se that provided early human societies with a survival advantage (McClennon 199\ 7).

Shamanism may constitute one of the earliest forms of religion, which, l\ ike later 168 Chapter 6 variants of religion, constituted an adaptation to inner anxieties and a\ culturally constituted defense mechanism for society facing significant environmental chal- lenges or dealing with confusing and crisis-torn times (LaBarre 1980).\ Shamans are found in societies such as the !Kung or San of the Kalahari \ Desert, the Semang of the Malay Peninsula, and the Jivaro of Bolivia. Wi\ nkel- man argues that shamanistic practitioners and somewhat similar magico-religious healers are found in technologically more complex sociocultural systems.\ He maintains that sociocultural processes have contributed to the disapp\ earance of shamans and other shamanistic healers. For example, in state societie\ s, these practitioners are in competition with the monopolistic claims of institu\ tional religions over which priests preside. The shaman does not completely dis\ appear in modern state societies but goes underground in the form of spirituali\ sts, faith healers, and New Age psychics and neoshamans.

Shamans among the !Kung Most adult males and some adult females among the !Kung of the Kalahari \ Desert of Namibia and Botswana function as shamans and perform community\ healing rituals about four times a month. Several men, who are sometimes\ joined by women, dance around a fire and a group of singers, thus inducing a \ trancelike state of “boiling” energy, or num. The healers may also ingest plant substances that contain num. While in trance !Kung healers treat sick spectators by implor- ing the ancestral spirits to restore them to health. Among the !Kung and\ other foraging societies, shamanic healing techniques tend to be public becaus\ e they are utilized by numerous individuals in the group. Healing techniques te\ nd to be focused on immediate restoration of well-being or accommodation to de\ ath through ritual activities and social practices. In a classic work on health-related issues among the Yirrakala or Yolngu\ , who were traditionally foragers, of northeastern Arnhem in the Northern Territories of Australia, two types of healers were identified: the marrnggitj, or traditional healer, and the raglak, or sorcerer (Reid 1983). Some individuals become a mar- rnggitj in the wake of a frightening supernatural experience in which a spirit \ con- fers healing powers on them. Ultimately, of course, the prospective trad\ itional healer must have the ability to counteract sorcery or the work of the raglak to consistently attract patients. Reid found only two men, a boy, and a wom\ an who still practice aboriginal medicine in the Yirrakala vicinity. Not all foraging societies have shamanic healers per se. A case in point\ is the Penan, a group in Brunei Darussalam on the island of Borneo in Indon\ esia who were traditionally hunters and gatherers but who are in the process \ of being transformed into village horticulturalists. Voeks and Sercombe (2000) argue that the rudimentary medical belief system associated with their foraging lif\ estyle is a consequence of the fact that they did not suffer from many debilitating \ diseases, as was the case with surrounding village peoples. Nevertheless, the Pena\ n do recognize the existence of numerous unnamed spirits that can inflict h\ arm on humans for violating various taboos and rely on “dream readers” to\ divine the sources of illness episodes, but they often disregard the advice of thes\ e medical practitioners. The Hadza, a foraging people in Tanzania, do not have any\ med- ical specialists other than women who perform clitoridectomies. Every ad\ ult has Ethnomedicine 169 knowledge about medicinal plants and can treat anyone with an illness. I\ n addi- tion to shamans, the Toba, a traditionally foraging society that engaged\ in some horticulture, have herbalists (some of whom today are called curanderos and act as healers in Christian evangelical sects) and other specialists who tr\ eat specific illnesses, such as those found among infants and children. Historically shamans have tensions with state societies and established \ churches (Oppitz 2013:25). Nordic state societies beginning in the eig\ hteenth century confiscated drums used by Sami shamans. Siberian shamans encountered repression on the part of the Russian empire under Czar Peter the Great,\ the Russian Orthodox Church, and the Stalinist purges during the Soviet era.\ Bud- dhist lamas suppressed shamans in Mongolia and Tibet.

Health, Illness, and Medicine in Village-Level Societies Village-level societies, such as the Ainu of Hokkaido in northern Japan \ and the Yanomamo in the Amazon basin of northern Brazil and southern Venezuela, \ are characterized by the appearance of specialized healers, elaborate he\ aling ceremonies attended by community members, and an expansion of the sick r\ ole manifested, for example, in growing attention to the psychosocial needs \ of sick individuals. The healer role in these societies confers social power on \ “individu- als selected in part because of their psychological, social and politica\ l as well as strictly medical talents” and who are in a position to “profit f\ rom positive and favorable outcomes of healing” (Fabrega 1997:99). As is the case in foraging societies, shamans are also often found in vi\ l- lage-level societies. For example, among the Yanomamo, shamans call the \ spirits, who take the form of tiny humanoids, to implore them to release their vi\ ctims from disease. Conversely, women are the primary repositories of herbal l\ ore that is derived primarily from wild plants but also from some cultivated\ ones.

Yanomamo shamans, called shapori, in their capacity as “masters of the spirits” perform both benign and malevolent acts, curing members of their communi\ ty but attacking and reputedly killing enemies in other villages (Jokic 20\ 14). The Fore, a New Guinea highlands horticultural people who, like the Yanomamo, had a village-level society at the moment of contact with Euro\ pean expansion, depend on what they call Dream Men or Smoke Men, healers who \ rely on dreams and hallucinations induced by inhaling tobacco smoke in o\ rder to identify offending sorcerers. The Warao of Venezuela have three types of shamans: priest shamans, ligh\ t shamans, and dark shamans (Wilpert 2004). Priest shamans induce a tran\ ce by consuming tobacco and take spirit journeys that take them past monsters \ to an ancestral mountain where they will eventually reside after they die. Whi\ le still alive, however, they obtain assistance from the ancestors in punishing p\ eople who threaten harmonious relationships with the ancestors. Light shamans come\ from the land to the east where the sun rises and are connected with the Toba\ cco Spirit.

While they use a sucking cure when treating patients, they function as assault sorcerers by casting arrow-like projectiles at enemies. Dark shamans are\ associated with the setting sun and Hoebo, a spirit that takes the form of a red ma\ caw that drinks human blood. They are likened to vampires and blood-sucking insec\ ts. 170 Chapter 6 The Dani, a horticultural village people who also inhabit the New Guinea highlands, have two types of magico-religious healers. One type is the hathale, who tend to be women who carry out a variety of medico-religious functio\ ns, ranging from serving as midwives, carrying out abortions, administering \ medic- inal herbs, and performing simple curing ceremonies or even allegedly ca\ sting spells. The other type includes political leaders who seek to appease th\ e ancestral spirits by sacrificing pigs in order to ensure fertility both among wo\ men and in garden plots as well as general health and prosperity. Robert Desjarlais, a medical anthropologist, participated in some twenty\ healing rituals as a shamanic apprentice to a sixty-five-year-old heal\ er called Meme during his fieldwork among the Yolmo Sherpa, an ethnically Tibeta\ n horticultural people residing in the Helambu region of north-central Nepal.

Desjarlais (1992:241) notes that while Yolmo shamans often are not suc\ cessful in their efforts to cure primarily physical ailments, such as arthritis or \ tuberculosis, “they are adept at healing illnesses related to personal distress or \ social conflicts (especially when compared with biomedical treatments).” Recovered patients in various horticultural village societies became members of curer societies or sodalities. The Ndembu, who reside on a wooded pla\ teau in the Mwinilunga District in the North-Western Province of Zambia, are \ a case in point. According to Victor Turner, a diviner who diagnoses the source\ of patients’ afflictions resulting from an offended spirit directs his\ clients to a senior practitioner who propitiates the spirit and assigns a “band of adepts, consisting of persons who have themselves undergone as patients or novices” port\ ions of curative ritual. He observes, “If the patient is deemed to be cured, \ he or she may then assist at later performances as an adept” (Turner 1968:16). Wh\ ereas the term “wounded healer” was initially applied to shamans (Eliade 19\ 64), the con- cept may also be applied to other types of healers, including diviners o\ r ngoma practitioners in Swaziland of southern Africa. In Swazi traditional heal\ ing the person possessed by an evil spirit can be healed while undergoing traini\ ng as a diviner. Furthermore, “suffering certainly is a lived reality for div\ iners, but as a sign of a calling it is also an ideology” (Reis 2000:73). Health, Illness, and Medicine in Pastoralist Societies The Datoga, a pastoral people in Tanzania, make a distinction between an\ “ill- ness of God” and an “illness of human beings,” although many il\ lnesses may be ascribed to both agents. Human-caused illnesses include witchcraft (generally believed to emanate from neighboring indigenous groups), the evil eye, \ and the administration of poisons. Male healers belong to one of two healing\ clans and treat patients by spitting on their bodies as a type of blessing rit\ ual that may be combined with the application on patients’ bodies of mixtures of h\ erbs and animal fat. Women healers, who are far fewer in number, function as medi\ ums through which patients can petition the spirits for advice or a cure. The Tuareg, a traditional pastoral people found in the Saharan and Sahelian areas of\ West and North Africa who have been heavily influenced by Islam, believe that d\ isease may be a result of imbalances of hot and cold in the body, malicious gossip,\ or sor- cery. The Tuareg have a wide array of healers to which they can turn, in\ cluding Ethnomedicine 171 herbalists, bonesetters, Islamic religious healers, diviners, and exorcists. Like many pastoral peoples around the world, the Tuareg have been influence\ d by the medical practices of other peoples, particularly the Hausa, another Isla\ mic group.

The Mongols, the most renowned and feared pastoral nomads in human histo\ ry, blended their naturalistic practices, including massage, bone setting, m\ idwifery, and shamanistic practices that called on spirits to alleviate disease or misfortune, with medical beliefs and practices from first Tibetan Buddhism and lat\ er Russian biomedicine.

Health, Illness, and Medicine in Chiefdom Societies According to Fabrega (1997), chiefdom (or prestate) societies, such \ as those of Hawaii and the Maori of Polynesia; the sedentary foraging societies o\ f the Pacific Northwest Coast; and early state societies, such as Sumer, a city-state in Mesopotamia, exhibit the beginnings of the “institution,” or “\ system,” of medicine, which includes (1) an elaborate corpus of medical knowledge \ that embraces aspects of cosmology, religion, and morality and (2) the beginnings of medical pluralism (a topic on which we elaborate in chapter 7), manife\ sted by the presence of a wide variety of healers, including general practitione\ rs, priests, diviners, herbalists, bonesetters, and midwives who undergo systematic t\ rain- ing or apprenticeships. Traditional Maori recognize two categories of di\ sease:

matetangata (those caused by human mishaps) and mate atua (those caused by supernatural forces). As in other parts of Polynesia, both types of dis\ eases ema- nated from a violation of a tapu, or social norm that invoked the wrath of the gods. Tohunga, or traditional healers, either recited chants to induce religious healing or prescribed medicinal plants. Some male healers, or fojo, in Samoa, another Polynesian chiefdom society, are also chiefs, and some women healers are the wives of chiefs. The for\ mer tend to restrict their practices to kinfolk whereas the latter do not. S\ ome fojo are general practitioners who treat a wide range of ailments and others are \ specialists who treat either natural illnesses or supernatural illness, or employ ce\ rtain med- ical procedures, such as massage or administration of herbs. Healers als\ o vary in their range and depth of knowledge of the disease etiology and diagnosti\ c and treatment techniques (Macpherson and Macpherson 1990: 102, 117–18, 1\ 40).

Folk Healers in Modern Societies A wide variety of folk healers continue to function in modern societies,\ par- ticularly in developing societies but also in developed societies. These\ include herbalists, bonesetters, lay or direct-entry midwives, and religious hea\ lers. Even shamans persist in modern societies, including in urban areas. Indeed, s\ hamanism has undergone a resurgence in parts of Siberia since the collapse of the\ Soviet Union, in large part as a form of ethnic identity. Indeed, the Russian g\ overnment now recognizes shamanism as an official religious tradition. Konstantinos Zorbas (2017) conducted 18 months of ethnographic researc\ h on shamanism in Kyzyl (population approximately 100,000), the capital \ city of Tuva Republic situated near the Mongolian border. Shamans in Kyzyl opera\ te 172 Chapter 6 either under the umbrella of three shamanic associations or independentl\ y.

All shamans in Kyzyl both engage in healing rituals and place curses on \ individ- uals who have placed a curse on a client. Kyzyl residents often express hostile impulses through supernatural retaliation facilitated by a shaman, thus making shamans a “cultural equivalent of the justice system, by virtue of th\ eir ‘super- natural’ power (sanctioned by this culture) for redressing injustic\ es” (Zorbas 2017:146).

Female Shamans in Central Asia Many folk healers in modern societies are women. Ironically, while Islam only allows men to be religious leaders, known as mullahs, and while Islamic clerics in Central Asia sought to do away with shamanism, they were not successf\ ul in doing so and women found a niche as religious leaders within the paramet\ ers of shamanism. Razia Sultanova (2011), a scholar of female shamanism and S\ ufism, reports that in Central Asia shamanism took on a Muslim texture. For exa\ mple, shamans in their ritual first appeal to Allah, then the Muslim saints,\ and finally to the helping spirits or jinn mentioned in the Quran. Female shamans in Cen- tral Asia have also embraced Sufism, a mystical form of Islam popular \ in Iran, Iraq, Central Asia, and North Africa, which traditionally is famous for \ induced trance-like behavior through ecstatic dancing. Central Asian women often play musical instruments that historically were associated with shamanism but became incorporated into Sufism.

Arab Women Healers in Israel Israeli anthropologist Ariela Popper-Giveon (2015) has written a fasci\ nating account of Arab women healers, referred to as Sheikha, Darwisha, Haijah, or Fataha, and their patients in Israel, a society in which they are a part of a heavily discriminated ethnic minority. She conducted ethnographic research on Arab women healers in two settings—urban Arab society in central Israel and Bedouin society in the Negev Desert. Arabs in Israel are discriminated a\ gainst in numerous ways, including in terms of access to education, employment,\ health care, politics, and living areas. Other than a few urban Arab Chr\ istians, most Israeli Arabs are Sunni Muslims, at least culturally if not religio\ usly. While Arabs living on the West Bank and Gaza live in apartheid-like conditions\ , Arabs living in mixed-population cities in central Israel come into contact wi\ th the Jewish population, even residing in the same neighborhoods, working toge\ ther in factories and offices, and visiting the same shopping malls, restau\ rants, and cafés. They also listen to Hebrew radio stations and read Hebrew newspapers and their children often attend schools where they study with Jewish students who are numerically and sociologically the majority group. In contrast, \ the Bedouin Arabs living in the Negev Desert generally experience only indir\ ect contact with Jews, finding themselves living in separate housing, atte\ nding separate schools, and participating in separate leisure activities. Bedo\ uin Arabs in the Negev tend to speak primarily Arabic in everyday life and maintai\ n con- tacts with people in Arab countries, particularly Jordan and Lebanon and\ even Saudi Arabia. Ethnomedicine 173 Popper-Giveon worked with a sample of twenty women, five women healers\ and five patients in her urban group and five women healers and fi\ ve patients in her Negev group. Most of her informants were fairly fluent in Hebre\ w, particularly those living in urban settings. Popper-Giveon (2015:26) describes her position as a Jewish Israeli woman studying Arab Israeli women as an\ out- sider-insider, noting that in some ways she was alien to the women whom \ she interviewed and in other ways she was a kindred spirit in that she conducted the interviews in Hebrew and in her own country. Traditional Arab women healers in Israel rely on a wide array of treatme\ nt techniques. The amulet (hajab), however, is a central device used in healing, particularly in the treatment of problems induced by the evil eye or mag\ ic spells:

“despair, depression and anxiety; extended bachelorhood; sterility an\ d livelihood problems” (Popper-Giveon 2015:84). Arab women healers also often re\ ad verses from the Quran in treating problems emanating from magic spells or the e\ vil eye.

Magical potions, consisting of bodily organic matters, such as menstrual\ blood, secretions, nails, hair, and urine may be used in counter-spells to ward off evil caused by an enemy. They may also be used as love charms for arousing a \ man’s desire or maintaining a woman’s fidelity and love. Popper-Giveon contends that the traditional Arab women healers and their patients in her study experience dual discrimination, as members of the \ Arab minority and as members of a patriarchal Muslim community. She maintains that traditional Arab healing constitutes a coping mechanism for both the hea\ lers and patients in her sample in dealing with the numerous personal and social \ vagaries in their lives. Women healers achieve personal power, self-esteem, economic benefits, and respect from their families and communities. Women patie\ nts also feel personally empowered by the treatments that they receive, not only \ ritually but in terms of advice and social support. Conversely, the traditional Arab women’s healing complex does not pos\ e a threat to the repressive structure of Israeli society, even if it consti\ tutes the ulti- mate source of patients’ problems. As Popper-Giveon (2015:255) obse\ rves, the “healers do not involve themselves in the overt public activity of va\ rious organi- zations and governments agencies, nor do they join forces with one anoth\ er to consolidate and entrench their power.” In reality, the healers often \ compete with each other for their patients’ affection and financial payments. Fu\ rthermore, Arab women’s healing serves to reinforce traditional patriarchal patterns.\      Case Study: Are the Therapeutic Aspects of Religion Something That Partially Address Refugee Health Problems?

In chapter 2, we touched upon migration and refugee health issues, a topic that organizations such as the UN, WHO, and the World Bank have acknowl- edged. The United Nations (2017) estimates that 65.6 million people we\ re inter - nally displaced worldwide in 2017 for a wide variety of reasons, such as civil 174 Chapter 6 wars but even in order to move indigenous and peasants in order to protect endangered animal species and environmental degradation purportedly caused by these populations. While environmentalists often support such programs, they often overlook the social and health impacts upon the displaced popula- tions. Anthropologist Jeffrey G. Snodgrass and two of his colleagues in other disciplines investigated in a highly quantitative manner the mental heal\ th benefits of religious rituals among indigenous Sahariya conservation refugees who had been displaced from a wildlife sanctuary in central India to make room for Asiatic lions from a neighboring area (Snodgrass et al. 2017). Bronislaw Malinowski (1954), a pioneer anthropologist, discussed how magical and religious rituals serve to alleviate anxiety and instill a sense of personal empowerment in uncer - tain situations, ranging from hunger, the danger of predation, whether the crops will grow, or the possibility of death in particular. Conversely, other anthropolo- gists have argued that religion can instill anxiety and fear in people in that it often poses the possibility of punishment from ancestral or other spirits for violating social norms. Fundamentalist Christians often argue that unrepented sin can result in eternal damnation in hell.

The Sahariyas are one of some seventy-five proto-horticultural, largely for - aging groups, referred to as Adivasis, meaning “first inhabitants” or “aboriginal peoples.” They are poor, generally illiterate, and live in remote geographical areas, but historically have formed linkages with Hindu communities with w\ hom they exist in patron-client relationships. Sahariya have adopted Hinduism and participate in Hindu festivals, such as Holi, the Hindu Festival of Colo\ rs, and Navrati, the Nine Nights of the Goddess, which occurs shortly after Holi\ .

The research team surveyed 159 Sahariya heads of households, 78 in a relocated village called Maziran and 81 in a buffer zone control village called Behruda. It proposed four hypotheses: H1. Health indicators would improve over the course of the festivals, with the greatest improvement occurring at peaks in the celebration; H2. Health improvements would be greatest among the more affluent Sahariya; H3. Health improvement would be affected by perceived insecurity; H4. Health improvement would be the greatest for Sahariya who were suffering from a more serious psychiatric ailment. The team measured diurnal cortisol, stress, and PANAS (Positive and Negative Affect Schedule) levels for each subject over the course of the festivals\ . Based upon these measures, they found that ritual participation in both Holi and Navrati “promotes positive over negative psychosomatic experience” (H1; Snodgra\ ss et al. 2017:271). The researchers also found physiological and psychiatric sup- port for hypotheses 2, 3, and 4.      Ethnomedicine 175 Biomedicine as the Predominant Ethnomedicine in Modern Societies Various scholars have debated the time of the emergence of biomedicine a\ nd its branching off from the traditional allopathic medicine that was prac\ ticed, for example, during the colonial era in the United States. Michel Foucault a\ rgued in The Birth of the Clinic (1975) that biomedicine emerged around 1800 in Europe as it systematically began to classify diseases into families and species and focused more on the body, thus the term the “clinical gaze,” t\ han on the ill person. According to Foucault (1975:169), “Clinical experience sees\ a new space opening up before it; the tangible space of the body . . . the medicine of organs, sites, causes, a clinic wholly ordered in accordance with pathological a\ natomy.” He went on in subsequent writings to portray medicine as one of a series\ of forms of social control, along with the state and prisons. Chrystal Jaye and her col- leagues apply Foucault’s social constructionist analysis of biopower to biomedical education at the University of Otago on the South Island of New Zealand (Jaye et  al. 2006). Based upon interviews with preclinical medical students, cli\ nical instructors, and medical educators, they observed that the new crop of b\ io- medical students is expected to be more humane, compassionate, and cultu\ rally sensitive than their mentors, in essence internalizing new forms of subj\ ectivity: These new subjectivities are subject to scrutiny through surveillance te\ chniques that assess behaviours and attributes such as reflectivity, self-awarene\ ss, pa- tient-centredness, humanitarian values, ethics and maintenance of profes\ sional boundaries. Mechanisms of formative and summative feedback constitute re\ - gimes of normalizing judgment from teachers—but these normalizing jud\ g- ments are also exercised through subtle positive and negative reinforcem\ ents from within the learning environment as successive generations of doctors teach the new generation what it needs to know. (Jaye et al. 2006:150–5\ 1) In contrast to the social constructionist perspective adopted by Jaye an\ d her colleagues in their analysis of biomedical education, Brian McKenna \ (2010) applies a critical medical anthropological perspective in his analysis o\ f biomedical education at Michigan State University. He examined a six-year project c\ alled the Community/University Health Partnership, which aimed to produce more\ community-oriented primary care practitioners. Because the project chall\ enged biomedicine’s orientation toward curative care, professional rivalry,\ overspecial- ization, and hospital-based education, it met with stiff resistance and \ ultimately collapsed, despite support from a dean who ultimately resigned from his position. Biomedicine is often depicted as an example of a profession par excellen\ ce because its physicians generally enjoy prestige, high incomes, relative \ autonomy over work, and a monopoly over the prescribing of dangerous drugs, declaring people mentally incompetent, signing birth and death certificates, and referring patients to other health practitioners. Freidson (1970) likens the pos\ ition of biomedicine in modern societies to that of state religions in preindustr\ ial civiliza- tions. But state religions as instruments of social control were always \ subordinate to the wishes of ruling elites of their societies. Thus, the professiona\ l dominance 176 Chapter 6 of biomedical physicians is delegated rather than absolute. The corporate class and its political allies in advanced developed and many developing societies\ delegate power to biomedicine in the form of financial support and licensure or\ statutory registration (Baer 2001:46–47). Biomedical physicians also often ar\ e highly rep- resented on the registration boards of other biomedical health practitio\ ners, such as nurses and allied health professionals. They also tend to be overrepr\ esented on hospital boards, government health departments, health advisory boards, the National Institutes of Health, and the World Health Organization. Nu\ rses and allied health workers often embark upon drives for professionalizati\ on that emulate the training and organizational structures of their biomedical s\ uperiors. In recent decades, biomedical physicians have encountered challenges to their professional dominance from several quarters, including new models\ of health focused on prevention, the social determinants of health, and com\ munity; the rise of corporate medicine with its strong emphasis on managed care;\ the changing nature of state involvement and regulation, which includes cost\ -cutting measures and performance indicators; the lessening public status of biom\ edi- cine due to media exposés of medical fraud and negligence; the recogn\ ition of patient rights; and the increasing popularity of complementary and alter\ native medical systems. Beginning in the early 1970s, particularly in the Unite\ d States, an increasing number of biomedical physicians became salaried employees \ rather than independent entrepreneurs. Scholars began to see biomedicine as a “\ big business” manifested in an array of large health-care corporations an\ d proprietary hospitals that were part and parcel of a medical-industrial complex (Wo\ hl 1984).

While biomedical physicians tend to enjoy considerable prestige in most \ societies, in some developing societies their status is relatively low or declining\ . For exam- ple, in Mexico, biomedical physicians constitute the least prestigious p\ rofession out of the ten most popular professions and earn less than engineers, la\ wyers, and architects (Harrison 2000:301–2). In 1993 about a quarter of Mexica\ n biomed- ical physicians were unemployed or underemployed, although many rural ar\ eas lacked biomedical physicians.

Hospitals The hospital is the primary biomedical health-care setting in the provis\ ion of not only acute care but also outpatient services, such as lab work, X-rays, \ physical therapy, and programs addressing alcohol and drug addiction, weight reduction, and fitness. The hospital started out as a charitable institution that\ served as a last resort for the critically ill poor. In the nineteenth century, affl\ uent patients received health care at home administered by either a house-calling phys\ ician or a full-time private-duty nurse. Hospitals come in different forms, such as\ voluntary community hospitals, or religiously supported hospitals, proprietary hos\ pitals, and public hospitals. Hospitals may be general in scope or specialized, \ such as in the case of mental or heart hospitals. The hospital has evolved into an elaborate social system with subsystems\ and a wide array of occupational subcultures, including those of administrat\ ors, phy- sicians, nurses, medical technologists, and even patients. The hospital is a highly Ethnomedicine 177 authoritarian (some would even say quasi-militaristic) organization where orders are to be executed without question. It manifests a dual pattern of auth\ ority consisting of (1) administration, which includes a board of trustees, \ adminis- trators, and paid staff, and (2) medical staff, some of whom are paid employees but others who are visitors, and an elaborate occupational support struc\ ture that includes nurses, nurse aides, medical technologists, therapists, social workers, orderlies, and (in teaching hospitals like the one studied by Katz as d\ escribed in chapter 2) medical students as well as, sometimes, medical anthropologi\ sts. Reg- istered nurses function in two worlds in that they are responsible for c\ arrying out administrative policy and regulations and serve as the physicians’ re\ presentative on the floor by carrying out orders for patients. At the same time, nu\ rses have struggled to define their own arena of expertise, emphasizing the “care” aspects of healing as opposed to the “cure” activities undertaken by physi\ cians. Increas- ingly, however, with the rise of the nurse-practitioner and related role\ s (e.g., nurse-anesthesiologists), nurses have penetrated the curer role as well\ . Patients often experience culture shock, a term used by anthropologists for adjusting to the challenges of life in a culture that is foreign to them\ , on being admitted to the hospital because they undergo an ordeal of depersonaliza\ tion, loss of self-identity, exposure to unfamiliar jargon, and a “strippin\ g” process in which they must check their personal belongings and forgo many preferenc\ es.

They find themselves in a state of total or near-total dependency in w\ hich they are fed meals not of their own choosing, may be bathed by strangers, rec\ eive medications at all times of the day and night, and must wear standardize\ d, ill-fitting, and, for many people, far too revealing clothing. Poked, \ prodded, questioned, and awakened for testing at odd hours, they often respond by\ trying to personalize their immediate space by decorating their room or section\ of a room with gifts from friends and relatives or pictures from home, someti\ mes get- ting cranky or resistant, and, for many people, asking frequently when t\ hey can “go home.” Hospitalization, in short, is often experienced as a ki\ nd of sacrifice that is endured in exchange for the hope of returning from the world of \ the sick to the land of the well. An increasing number of health anthropologists conduct both teach- ing and research activities in hospitals. Some of this work is carried o\ ut by physician-anthropologists, but even more of it is carried out by nurs\ e- anthropologists, many of whom belong to the Council of Nursing and Anthr\ o- pology, a constituent unit of the Society for Medical Anthropology. With\ in this context, some health anthropologists are involved in what is termed clin\ ical anthropology or clinically applied medical anthropology. Much of this wo\ rk occurs in hospitals or other clinical settings and often involves the an\ thropologist serving as a cultural translator who facilitates the physician-patient relationship.

In contrast to sociologists Gail Henderson and M. Cohen, who produced a \ book-length ethnography of the Second Attachment Hospital complex on the\ outskirts of Wuhan, the fifth-largest city in China, no anthropologists to date have conducted an ethnography of an entire hospital. Nevertheless, in keeping with a growing interest in hospital ethnography, Anna Harris (2009), a biomedical physician, conducted an in-depth stud\ y of how 178 Chapter 6 overseas biomedical physicians, particularly ones from developing countr\ ies, in two outer suburban hospitals in a large Australian city have adjusted to the larger national health-care system as well as the larger society. In addition t\ o learning about a different hospital system and its biomedical routines and proced\ ures, they spent much of their time “improving their English language fluency,\ sorting out their visas, making sure their families were settled and they had a dece\ nt salary to support them.” In addition to occupying the less prestigious positions in urban hospitals, overseas biomedical physicians in Australia increasingly fi\ nd themselves practicing in “country towns” or rural areas, places that domestic\ Australian general practitioners and specialists have in many instances abandoned. \ Beyond the hospital is the clinic or health station, often set up in more isola\ ted, lower population density, and rural areas to serve the health needs of dispers\ ed com- munities. The health station, like the one studied by Leslie Butt (fi\ gure 6.2), is especially important in areas with limited health budgets and comparativ\ ely fewer medical professionals. As health anthropology has evolved, it has taken on new topical interest\ s, including ones intimately related to biomedicine. Two of these new topic\ inter- ests are pharmaceuticals and biotechnology, both of which touch on the a\ nthro- pology of the body.

Health Anthropology and the Pharmaceutical Industry Health anthropologists have become increasingly aware of the importance \ of studying the enormous pharmaceutical industry; pharmaceutical drugs are dis- pensed around the globe with tremendous impact on health and health beha\ vior and are used in ways that are culturally meaningful, whether or not they\ are in line with or reflect medically approved patterns of use. Etkin (1988)\ , for example, has examined the cultural construction of the efficacy of pharmaceutic\ al drugs Nurse-Anthropologists and Physician-Anthropologists Many nurses have found anthropology and specifically health anthropology to be of great utility in their work. Consequently, numerous undergraduate nursing pro- grams require their students to take a course in cultural anthropology, and many nursing schools now teach courses in health anthropology and related subjects.

Indeed, many of the people teaching these courses are nurses who have obtained graduate degrees in health anthropology.

Some anthropologists have argued that, in contrast to biomedical physicians, who tend to be “disease oriented,” nurses are inclined to be more “person oriented.” Conversely, while many biomedical students regard medical anthropology and related fields to be intrusions in their demanding studies, medical anthropology includes some prom- inent physician-anthropologists, including Arthur Kleinman and Paul Farmer, both of whom are based at Harvard University and have had significant productive influence on health anthropology. Ethnomedicine 179 in light of varying cultural understandings of what efficacy means. Wh\ ile phar- maceutical drugs are intended to have specific physical, emotional, or\ behavioral effects, their effectiveness may be judged by quite different standards \ in local cultural settings. Moreover, to understand the impact of the pharmaceutical industry we mus\ t recognize its global character: “a pharmaceutical company might have \ its corpo- rate headquarters in the United States, [test its drugs in Uganda], prod\ uce its drugs in Ireland, assemble its capsules in Brazil, and sell the products\ in Bolivia” (Bodenheimer 1985:190). Furthermore, pharmaceutical/biotechnology com- panies cannot be pinpointed to one location; they function as any multin\ ational corporation does, worldwide (Mehrabadi 2005). Operations are carried out depending on the price of labor, where raw materials are the least expen\ sive, where taxes can be easily evaded, and where market regulations are the l\ east strict. As a result of the pharmaceutical industry’s global reach, its products appear in societies that lack a developed health-care infrastructure, sometimes\ with dra- matic effect. In the case of El Salvador, for example, the arrival of ph\ armaceutical drugs pushed out locally produced indigenous medicines and the healers w\ ho FIGURE 6.2 Government health post in the highlands of western Papua New Guinea. Photo by Leslie Butt. 180 Chapter 6 produced and dispensed them (Ferguson 1981). Local community structure\ s then began to break down. In a similar case in South India, the traditio\ nal use of herbal remedies has been overwhelmed by the widespread sale of pharmaceu\ tical drugs, which were associated by local populations with modernity and pro\ gress (Nichter 1989). By using Western medicines, in effect, people are atte\ mpting to reap the benefits of development, including the standard of living \ and con- centration of wealth found in Western countries. In this sense, pharmace\ uticals sometimes acquire culturally constructed fetishized qualities in the sam\ e sense that possessing a lucky charm will bring personal fortune. The popularit\ y of pharmaceuticals internationally has led to the formation of an informal \ sector for the distribution of commercial drugs, such as folk injectors who give si\ ngle shots of antibiotics in community markets in various countries. Given the need\ for receiving a course of antibiotic treatment, not only is this emergent fo\ lk practice ineffectual from a medical standpoint, but it can also contribute to the\ develop- ment of strains of bacteria that are drug resistant. In Cameroon, for ex\ ample, there is evidence not only that self-medication with pharmaceutical drug\ s can be detrimental to health but also that the available resources of low-incom\ e house- holds are wasted on useless medication (van der Geest and Whyte 1988).\ Moving from the micro level to the macro level, we can see that because \ pharmaceutical corporations are profit driven, their actions are not n\ ecessarily shaped by a health agenda, sometimes with significant health consequen\ ces.

For example, in 2005 the pharmaceutical company Eli Lilly agreed to plea\ d guilty to a single misdemeanor count and to pay a fine of $36 million \ for its violation of the Food, Drug, and Cosmetic Act in its promotional campaig\ n for the anti-osteoporosis drug Evista (Corporate Crime Reporter 2005). According to this law, pharmaceutical companies must specify the medical purpose(\ s) of new drugs in their applications to receive marketing approval from the F\ ood and Drug Administration (FDA). Once the FDA approves a drug, it can be leg\ ally promoted and sold only for the purposes for which it has been approved. \ Pro- motion for what is called “off label” uses is outlawed. In the cas\ e of Evista, Lilly executives were disappointed with sales levels during the first year t\ hat the drug was on the market; it brought in only about a fourth of the projected an\ nual sales of $400 million. To make up for this loss in expected income, Lilly decided to widen the market for its drug by promoting it for several unapproved \ uses.

Although application by Lilly to the FDA to include these new uses was r\ ejected, the company began pushing use of the drug in the prevention of breast ca\ ncer and cardiovascular disease. The consequences of such action are not triv\ ial in that doctors, assuming that the drug is effective in cancer and heart di\ sease pre- vention, may prescribe it instead of drugs that have proven in clinical \ trials to be effective in treating these diseases. In its expanded promotion efforts,\ Lilly used a variety of strategies, including training sales representatives how to g\ et physicians to ask about other uses of Evista, sending unsolicited medical letters t\ o physicians promoting unapproved uses of the drug, distributing an “Evista Best P\ ractices” videotape that states that “Evista truly is the best drug for the pre\ vention of all these diseases” (referring to osteoporosis, breast cancer, and cardiovascular dis- ease), and distributing a medical reprint highlighting findings about\ the various Ethnomedicine 181 benefits of Evista that was written by company employees and paid consultants while hiding a line in the reprint that acknowledged that the effectiven\ ess of the drug in reducing cancer risk or cardiovascular disease had not been esta\ blished, among other legerdemain strategies to promote and sell Evista (M. Singe\ r 2007). In another case involving the painkiller Vioxx in which it appears that \ improper procedures were followed in clinical trials, it is estimated th\ at at least 25,000 heart attacks and strokes occurred after taking the drug (Bazerm\ an and Chugh 2006). In the estimation of one pharmaceutical drug expert, David Gra- ham, associate director for science in the Office of Drug Safety at the FDA, Vioxx may have contributed to the deaths of 88,000 to 138,000 people, putting \ it at the top of the list of known deadly pharmaceuticals to be released to th\ e public (M. Singer and Baer 2007). In summary, this chapter starts out with a discussion of several domains\ of ethnomedicine, such as ethnophysiology, ethnopsychiatry, and ethnopharma\ col- ogy. It also considers various indigenous and folk medicine systems; typ\ ologies of healing systems; an evolutionary model of disease theories and healing s\ ystems; biomedicine as the predominant ethnomedicine in modern societies with th\ e hospital as the central biomedical institution; and the relationship bet\ ween health anthropology and the pharmaceutical industry.

Discussion Questions 1. Discuss the concerns of the vari- ous domains and sub-domains in Quinlan’s over view of the pur - view of ethnomedicine (table 6.1).

What might be some types of cul- ture-bound syndromes other than the ones mentioned in this chapter?

2. Discuss the relationship between medicine and magico-religious rit- uals in traditional healing systems.

Conversely, what types of natural - istic techniques are found in tradi- tional healing systems around the world?

3. Based upon the evolutionar y model of disease theories and healing systems elaborated upon in this chapter, discuss the general features of health, illness, and medicine in family-level foraging societies, vil- lage-level societies, pastoral societ - ies, and chiefdom societies.

4. Give examples for the persistence of shamans and other folk healers in modern societies.

5. In what ways has biomedicine evolved into the predominant form of ethnomedicine in modern societies? Discuss the centrality of the hospital and the pharmaceuti - cal industr y to biomedicine. 182 7 Throughout this centur y and even before, there has been a general assump- tion—even a conviction . . . that folk and popular systems of health beliefs and practices would inevitably decline in modern and industrialized societies. . . . Yet this has not been the case. —Bonnie Blair O’Connor (1995:1) Introduction and Overview I n the previous chapter, we examined the concept of ethnomedicine and con\ - ceptions of health, illness, and medicine in family-level foraging, vill\ age-level pastoral, and chiefdom societies. We move on in this chapter to consider the phenomenon of medical pluralism in complex societies by examining it in \ two locales in developing societies, namely, a village in the Bolivian Andes\ and a city in Java, Indonesia, and then in a technologically developed society, nam\ ely, Aus- tralia. We then examine various typologies of plural medical systems but\ particu- larly stress the concept of a dominative medical system, which points to\ the fact that medical systems do not exist in a vacuum but rather reflect the cla\ ss, racial, ethnic, and gender relations and inequalities of the wider society. In a\ domina- tive medical system, several different healing traditions coexist in the\ same soci- ety, but one tends to be more closely aligned with the dominant social groups in that society and to be the dominant healing tradition as well. Indigenous or tribal societies exhibit a diversity of healing beliefs an\ d prac- tices as well as an array of different kinds of healers, but these tend to be rather loosely organized and often reflect idiosyncratic patterns resulting i\ n part from the fact that healers commonly are secretive about their medical knowled\ ge.

In contrast, state societies manifest the coexistence of a highly elabor\ ate array of medical traditions at both the conceptual and the practice level, a patt\ ern that health anthropologists call medical pluralism. In other words, the medic\ al system of state-level societies tends to be made up of various medical subsyste\ ms that coexist in a social environment that ranges between extensive cooperatio\ n and open conflict. We present three case studies of medical pluralism in three distinct soc\ io- cultural settings. The first is a small village in the Bolivian high p\ lain (altiplano) based on ethnographic research done by Libbet Crandon-Malamud, the secon\ d is an administrative/university city in Java based on ethnographic resea\ rch done by Steve Ferzacca, and the last is Australia based on social historical \ and ethno- graphic research conducted by Hans Baer (2009). Plural Medical Systems Complexity, Complementarity, and Conflict 7 CHAPTER 7 PLURAL MEDICAL SYSTEMS Plural Medical Systems 183 PLURAL MEDICAL SYSTEMS      A Case Study of Medical Pluralism in a Rural Area in a Developing Society: The Altiplano of Bolivia A classic case in research in medical pluralism is based upon Libbet Crandon- Malamud’s (1991) ethnographic fieldwork conducted between 1976 and 1978 on medical pluralism in Kachitu (pseudonym), a rural town on the Bolivian alti- plano. Kachitu is the center for a canton consisting of some sixteen tho\ usand Aymara Indians living in thirty-six communidades . The town proper has some one thousand residents consisting of three ethnoreligious groups: Aymara peas- ants, Methodist Aymara, and Catholic mestizos (those of mixed European and indigenous blood). Before the Revolution of 1952, the mestizos, who consti- tute about half the population of Kachitu, supervised the labor of the A\ ymara on behalf of the national elites, who generally resided in La Paz and other cities.

Since the revolution, the mestizos have been seeking to avoid poverty and are a socially fragmented ethnic category that includes teachers, small shop\ keep- ers, and poor occasional agricultural laborers. Before 1952, the Aymara, who make up another third of the village, lived in Indian communities that were heav- ily taxed or on haciendas (plantations).

Some Aymara were miners and some performed personal services, such as domestic work, for mestizos. Many Aymara peasants migrated to Kachitu from the haciendas upon acquiring land through fictive kinship ties with mes- tizos. Following the revolution and land reform, others moved to town and claimed land on the outskirts that had been confiscated from the mestizos. The Methodist Aymara are converts or descendants of converts to the Methodist church, which established a mission in Kachitu in the early 1930s. The Metho\ dist Aymara attended mission schools and became entrepreneurs who took over local administrative and political offices when the revolutionary government threw the mestizos out of these positions. They function as the economic an\ d political backbone of Kachitu. Crandon-Malamud (1991) argues that the \ people of Kachitu tend to conflate ethnicity and social class, noting that Aymaraness, mestizoness, and even Methodism constitute “masks for social class.”\ Themes Crandon-Malamud identifies four themes that permeate the dialogue about medical etiology and diagnosis in Kachitu—pervasive hunger, subordination, victimization, and exploitation—within the context of the Bolivian po\ litical econ- omy. Pervasive hunger is a by-product of race and differentiates the purportedly white elites from mestizos and Indians as a means to justify unequal access to the political process and economic resources. The second theme entails an economic system that exploits Indian labor, the third consists of caudillo (strong authoritarian leadership) political structures that suppress dissent on the part of 184 Chapter 7 rural mestizos and Indians, and the fourth is conflict that exists between mesti - zos and Indians.

Medical Subsystems Five different medical subsystems are used by those in Kachitu, depending on the diagnosis: Aymara home care, shamanistic or yatiri care, mestizo folk home care, biomedical clinical care, and hospital care in La Paz. Crandon-Malamud examines the intricate ways that the residents of Kachitu utilize the local plu- ral medical system for purposes of establishing their sense of cultural \ identity and obtaining the few resources available to them. Contrary to the wishes of biomedical practitioners and indigenous healers, decisions concerning illness etiology and diagnosis tend to be made primarily by patients themselves,\ their families, and other interested parties. Biomedical physicians who practice in Kachitu must abandon many of their preconceptions and adjust themselves to the local belief systems if they expect to establish rapport with their \ patients.

The various medical ideologies in Kachitu function as options that address differ - ent types of ailments. As Crandon-Malamud (1991:202–3) observes, “\ All things being equal, if one has tuberculosis, one goes to the physician in the Methodist clinic; if one suffers from khan achachi, one goes to yatiri; if one has a stomach upset, one resorts to medicinas casera [home care].” (Khan achachi refers to a sickness stemming from a phantom, khan achachi, who consumes meat, alco - hol, and other gifts that it demands from people.) Kachitunos, regardless of their social standing, tend to be pragmatic when it comes to seeking medical treatment. Medical dialogue serves as an idiom by which a person identifies his or her ethnic identity within the large\ r context of Bolivian society—one that is characterized by frequent economic crises, unstable governments, and military coups. Mestizos in Kachitu who find them- selves downwardly mobile may, in essence, gain access to greater health care by turning to Indian indigenous medicine. Crandon-Malamud argues that they use medical dialogue, namely, debate about the most appropriate explana- tions of disease etiology and therapies to eradicate disease, as a mecha\ nism of empowerment in the face of overwhelming external oppressive political- economic forces at both the national and the international level. Unfortunately, this medical dialogue has served as a rather limited form of empowerment\ and in reality serves more as a coping mechanism than an oppositional fulcrum within the larger Bolivian political economy and the global economy.

Status of Health Care in Bolivia in the Pre-Revolutionary Era Health services in Bolivia underwent a serious decline during the 1980s. The infant mortality rate at the time was the highest in Latin America, with\ a national average of over 200 per 1,000 live births in 1985, as high as 650 per 1,\ 000 live births in some rural areas, as opposed to 150 per 1,000 live births in 1975 Plural Medical Systems 185 (Morales 1992:135). Furthermore, half of the children between ages one and six were malnourished; 60 percent of school-aged children manifested goiter and 45 percent anemia due to iodine and iron deficiencies, respectively (Morales 1992:135).

Cuts in government spending contributed to a lack of potable water in 65 percent of urban households. Between 1960 and 1990 life expectancy in Boliv\ ia increased by only five years, from the mid-forties to about fifty, some twenty years less than more developed Latin American countries (Klein 1992:280).

To no small degree, Bolivia’s health problems and other socioeconomic problems emanate from a national social structure in which “the wealthiest 5 percent control 39 percent of the national income and the poorest 20 percent, only 2 percent” (Morales 1992:203), a situation which in part was corrected by the coming to power of a left-wing populist political party and indigeno\ us presi- dent in 2006.

Social and Health Conditions in Bolivia after the Election of Indigenous President Evo Morales President Evo Morales and his governing Movement Towards Socialism (MAS) party have adopted a policy of “communitarian socialism” and proposed a “Law of Mother Earth,” which stipulates living in harmony with nature. Morales called for Socialism of the South or Indigenous Socialism that includes ten “\ command- ments.” These call for the eradication of the capitalism in order to “save the planet”; ending wars that have benefited empires, multinational corporations, and selected families; developing “relations of coexistence” among the countries of the world; treating access to water as a human right; developing “clean ener - gies”; respecting Mother Earth; treating “basic services, such as water, electric - ity, education, health care, communications, and collective transportations” as human rights; consuming only what is necessary and seeking to consume lo\ cal products; promoting “cultural and economic diversity”; and developing a “co\ m- munitarian socialism that is in harmony with Mother Earth” (Derber 2\ 011:135).

The Bolivian legislature established eleven new rights for nature, including the right to life and for existence, the right to clean water and air, the right to be free from pollution, and the right to “not be affected by mega-infrastructure and development projects that affect the balance of ecosystems” (Bell 2016:81).

The MAS emerged as the political arm of the indigenous-peasant movement \ based in the department of Cochabamba in the mid-1990s and models itself\ upon an “assembly-style, rank-and-file democracy of peasant unions in\ region” that consisted in large part of coca growers who opposed the U.S.-supported “drug war” in the region (Webber 2011:3). Over the course of its ascent, the party has become more moderate as an urban, mestizo middle-class intelligen- tsia has assumed influence. The MAS has also sought to appease the capitalist class in the eastern section of Bolivia in terms of the assembly’s governance structure, in part to stave off a secession movement. Garcia Linera, whom 186 Chapter 7 Morales chose as his vice president in 2005, developed the notion of “Andean- Amazonian state capitalism.” In 2006 Morales signed a law that nationalized Bolivia’s natural gas reserves and required all foreign energy companies to renegotiate their contracts so that they would benefit the Bolivian people (Derber 2011:138). His administration embarked upon a program of “nationalization without expropriation,” which nationalized oil and natural gas reserves within Bolivia but did not want multi- national corporations in the hydrocarbon sector to cease operations, but enter into joint ventures with the government (Kaup 2015). Under this arrangement, foreign direct investment in Bolivia increased from $281 million in 2006 to $1.75 billion in 2013. In addition to providing financial support for social programs, the government’s profits from the hydrocarbon sector have substantially increased international monetary reserves in Bolivia.

Bolivia has embarked upon a program of food sovereignty by promoting local and sustainable food production, which seeks to allow peasants to obtain ownership of seeds, thereby breaking them for dependence upon agribusi- nesses that dominate seed production. Morales withdrew Bolivia from the World Bank and the International Monetary Fund and undertook nationalizing the oil, natural gas, and lithium resources, a move that required altering the constitution (Vattimo and Zabala 2011).

In January 2009, the Bolivian people in a national vote of 61.4 percent approved a new constitution declaring that Bolivia constitutes a “pluri-n\ ational state, communitarian state” based on respect and equality for all and a policy of providing communal access to water, work, education, health, and housing for all.

Despite the best of intentions, the movement toward implementing Morales’s vision of socialism has been slow and patchy. Bolivia under Morales has preserved private property rights, not undergone serious land reform mea- sures, and experienced fiscal austerity. In 2011 Morales slashed fuel subsidies in order to reassure foreign investors. Also the Morales government provides hundreds of millions of dollars in loans, export subsidies, and tax incentives to wealthy agricultural exporters and has expelled landless indigenous squa\ tters from large agricultural estates (Petras 2011:15). In essence, despite MA\ S’s stated commitment to socialism over the long run, Bolivia between at least 2005 and 2010 followed a “reconstituted neoliberalism” based largely on exports of natural gas, oil, and mineral resources (Webber 2011:232). Furthermore, while Morales initially embraced direct democracy, many coca growers upon whose support he relied in his ascent to the presidency feel that he has “slipped into old fashion patronage politics, rewarding friends and pushing opponents” (Grisaffi 2013:49). Despite Morales’s capitulation to neoliberal pressures and retreat from participatory democracy, there still exists a left-indigenous collection of critical thinkers committed to the transformation of Bolivia into a highly equita\ ble and environmentally sustainable society. Plural Medical Systems 187 On the positive side, poverty in Bolivia has been reduced from 60.6 percent of the population in 2005 to 43.5 percent in 2012 (Fidler 2014:18).

Under the Morales government, by 2012 life expectancy increased to 67 years, and infant mortality dropped to 33 per 1,000 live births (UNICEF 2013). Literacy has increased tremendously and there has been expanded rural electrification and access to employment, education, and health care.

The Bolivian government has created small state-owned enterprises that allow local producers input into their operation, and has allocated more than thirty-five million hectares of land as communal land or indigenous territories.

Perhaps the most profound contradiction of the “socialism for the twen- ty-first century” experiment in Bolivia is, on the one hand, ongoing \ reliance on fossil fuels for generating revenue, much of it for needed social programs, and, on the other hand, the government’s defense of Mother Earth. The case of Bolivia is a profound illustration that socialism cannot be achieved in one coun- try, especially one on the periphery of the capitalist world system, and th\ at the construction of socialism for the twenty-first century will have to be a\ process occurring in numerous countries.

Under the Morales government, indigenous medicine has achieved notable headway, particularly in terms of the institutionalization of indigenous medica\ l associations and the licensing of indigenous healers. Even prior to the \ Morales government, in 1984 with the creation of the Bolivian Society of Traditional Medicine Bolivia became the first Latin American country to start the pr\ ocess of legalizing indigenous medicine (Babis 2014). A new constitution approved in a referendum in 2009 explicitly acknowledged the rights of indigenous people, who comprise about 60 percent of the population (the highest percentage of indigenous people in all of the Latin American countries), “with a s\ pecial chapter devoted to indigenous medicine” (Babis 2014:290). In 2012 a National Register for indigenous medicine commenced with a unit for indigenous medicine in the nine provincial health offices. Accreditation under the registry requires that a practitioner show evidence of birth in Bolivia, be over thirty years of \ age, pos- sess a certificate from their indigenous community or indigenous association, have practiced for at least five years, and submit treatment reports for the prac- titioner’s last ten patients.

Situated between biomedicine and indigenous medicine one finds a rela- tively new category of health practitioners situated in Bolivian cities \ called los naturistas (LN) who seek to integrate indigenous medicine and natural medicine (Bruun and Elverdam 2006). They generally are mestizos but treat both mesti- zos and indigenous people. In addition to relying heavily upon herbal medicine, LNs may use biomedical devices such as sphygmomanometers, or refer their patients to a biomedical physician for ultrasound or other tests, with t\ he latter referring the patient back to the LN. 188 Chapter 7 A Case Study of Medical Pluralism in an Urban Setting of a Developing Society: A View from Central Java Steve Ferzacca, an anthropologist based at Lethbridge University in Canada, adopts a meaning-centered perspective, described in chapter 1, in seeking to unravel “phenomenological meanings of plurality of health care and perception in lives” (2001:5) among residents of Yogyakarta in the Republic of Indonesia. This city is the site of Gadjah Mada University (the country’s first postindependence univer - sity) as well as many other colleges, institutes, and vocational school\ s, and it is a mecca of the classical arts, dance, music, and literature. In addition to visiting var - ious biomedical clinics in Yogyakarta, Ferzacca conducted ethnographic research in Rumah Putri, a neighborhood within a subdistrict of the city consisting primarily of working-class people and lower-middle-class clerks, teachers, and public ser - vants. Like various other countries in Southeast Asia, Indonesia, particularly under President Suharto’s New Order, has promoted an authoritarian program of mod- ernization, or pembangunan (development), and westernization in the form of elab- orate Five Year Plans. Ferzacca (2001:210) views medical pluralism in Yogyakarta generally and among the residents of Rumah Putri specifically as a “social practice that produces hybrid forms of medicine,” that is, a mixture of traditional and modern medicine, utilized by people who lead “hybrid lives.” Medical plur\ alism in Yogyakarta is manifested largely in two broad forms: biomedicine and pengobatan tradisional, or traditional medicine. Biomedicine is practiced in clinics and hospita\ ls that serve as “entry sites into modernity where exposures to the hegemony of scientific medicine takes place” (Ferzacca 2001:68). It is more or less universally available to everyone on the Indonesian island of Java, particularly in urban areas, and is situated in vari- ous settings, including private biomedical clinics, public health center\ s, mobile units, integrated health posts, and numerous government health programs. It is provided not only by biomedical physicians but also by nurse practitioners and he\ alth cadres.

Many Javanese view biomedicine as a system that is useful in treating diseases (such as adult-onset type 2 diabetes, hypertension, and heart disease)\ associated with development or modernization, and hence they see it as complementing tradi- tional indigenous and newly emerging medical subsystems.

Medical Subsystems Traditional medicine itself consists of a wide array of medical subsystems, ther - apies, and practitioners, including herbalism, massage, the use of amule\ ts and talismans, patent medicines, Chinese herbalists and acupuncturists, Ayurvedic and Unani doctors, and indigenous Javanese healers and psychics. Dukuns, or traditional Javanese healers, practice various forms of shamanism, divin\ ation, exorcism, magic, midwifery, pediatrics, massage, spinal manipulation or bone setting, herbalism, and counseling and, rather than being valued as cult\ urally familiar, are often regarded with suspicion because they may seek to exploit patients or place curses on unsuspecting victims. Conversely, psychics, or Plural Medical Systems 189 paranormals, are generally held in high esteem as paragons of modernity and development. These individuals find missing persons, perform astrology, tell fortunes, foretell the future, heal the sick, and perform rituals at various public events and rites of passage. The paranormals in particular have found a \ devoted clientele among politicians, businesspeople, and professional people, includ- ing members of the Javanese intelligentsia, such as professors, film and music stars, and even Catholic priests. In essence, while associated with pengobatan tradisional , paranormals practice a hybrid medicine that blends traditional prac- tices with modern ones associated with Western and Eastern psychic traditions.

In summary, Ferzacca (2001) argues that medical pluralism in urban Java pro- vides a public sphere where both practitioners and patients can try to cope with everyday hardships of living under the domination of an oppressive regime intent on forcing them into modern life and the global economy.

More recently, an ethnographic research on the plural medical system in eastern Java examines treatment of mental illness, with a focus on three types of healers, namely the dukun, the kyai, and the psychiatrist (Woods 2007). The dukun is a traditional shamanic-like healer who may go into trance or se\ rve as a spirit medium and often touches the patient, sometimes gently and other \ times more forcefully. He or she may provide the patient with an amulet, water blessed by a prayer or spell, paper containing a magical formula, or an herbal m\ edicine.

The dukun seeks to create balance between the patient and the cosmos. The patient is expected to compensate the dukun for his or her services with a gift or money. Dukuns do not generally belong to professional associations and tend to be viewed with ambivalence in Javanese society.

In contrast to the dukun, the kyai is also a male practitioner who often\ sur - rounds himself with Islamic symbols and attire. He may perform either in a public or private setting and interprets symptoms as emanating from transgressions against Allah or people. The kyai prescribes amulets or prayers and admonishes the patient to observe the pillars of Islam. While he is believed to hav\ e supernat- ural powers, the kyai has studied Islamic law, history, and texts and is ultimately a representative of Allah. Unlike the dukun, kyais belong to a number of regional or national professional associations. For his services, the patient provides the kyai with a gift, food, or money, always given “surreptitiously in an offered palm or envelope” (Woods 2007:444).

Finally, the psychiatrist, while a biomedical specialist, does not dismiss the cultural appropriateness of the treatment administered by the dukun or kyai.

Psychiatrists, generally male, may see their patients in private clinics\ or hospitals, the latter which tend to be loud and chaotic settings in Java. They prescribe advice and medications in an authoritarian and often rushed manner and o\ ften dismiss many of the symptoms presented by their patients, although high-income patients may be treated in a more solicitous manner. Reportedly, Indonesian psy- chiatrists have been profoundly influenced by cultural psychiatry, particularly as manifested in the work of psychiatrist-anthropologist Arthur Kleinman. 190 Chapter 7 A Case Study of Medical Pluralism in a Developed Society:

The Australian Dominative Medical System Australia, which has about twenty-four million people in an area slightly smaller than the lower forty-eight U.S. states, is unique in that it has gone further than perhaps any other developed country in providing public support for the training of practitioners of complementary and alternative medicine (CAM), both in terms of degree-granting programs in chiropractic, osteopathy, Chinese medicine, and naturopathy in public universities and in terms of partnerships that have devel- oped between private CAM colleges and public universities that allow stu\ dents in the former to upgrade an advanced diploma into a bachelor’s degree. In con- trast, aside from public colleges of osteopathic medicine, which in the United States have evolved into a parallel medical system to biomedicine with a\ n emphasis on family medicine and reliance on manipulative therapy as an adjunct treatment approach, all training programs in chiropractic, Chinese medicine, and naturopathy are embedded in private institutions in both the United States and Canada. As the Australian case indicates, the manner in which medical pl\ uralism is expressed in a particular society is significantly shaped by political, econ\ omic, and social structural forces specific to that society, a point that was made in the case of Bolivia described previously. Whereas the Australian medical system with its various medical subsystems was relatively pluralistic in the nineteenth century, early in the twentieth century, with the transformation of regular or allo - pathic medicine into biomedicine, the latter adopted a scientific guise \ to distin- guish itself from heterodox or alternative competitors. The Australian medical system evolved into a plural system in which biomedicine achieved dominance over other medical subsystems, a configuration that medical anthropologists call a “dominative medical system” (Baer 2001). Table 7.1 depicts a model of the Australian dominative medical system.

Beginning in the late nineteenth century, Australia as a relatively open society conducive to maverick individuals and social experiments served as what one aptly terms a “paradise of quacks”—a veritable haven for homeop\ aths, herbal- ists, phrenologists, hydropaths, lay midwives, spiritual healers, and purveyors of home remedies and patent medicines (Martyr 2002). The nature of some of the medical subsystems in Australia is examined next.

Medical Subsystems Osteopathy Although initially developed in the United States, osteopathy diffused to vari- ous countries, particularly Anglophone countries, such as Canada, the Un\ ited Kingdom, Australia, and New Zealand, where, unlike in the United States, it has remained primarily a manual medical system. In contrast to various other \ coun- tries, the development of Australian osteopathy has been intertwined wit\ h that of chiropractic. Some Australian practitioners attempted to institutionalize a \ merger Plural Medical Systems 191 of chiropractic and osteopathy as was evidenced by names of various profes- sional bodies and training institutions (e.g., the Chiropractic and Osteopathy College of Australia). Several osteopathic colleges reportedly transformed them- selves into chiropractic colleges in the mid and late 1960s.

Chiropractic There have been at least four periods in the development of Australian chiro- practic: (1) the establishment period (1918–1953), in which various groupings of chiropractors emerged in Victoria, including ones drawn from the ranks of British-trained osteopaths and others who obtained chiropractic training in the United States; (2) the period of expansion (1954–1961), which wit\ nessed a con- siderable increase in the number of chiropractors trained in Australia (as well as many trained overseas); (3) the period of agitation (1961–1973),\ resulting in 1964 in the passage of the Western Australian Chiropractors’ Act, which provided TABLE 7.1 The Australian Dominative Medical System Biomedicine Fully legitimized professionalized heterodox medical systems Osteopathy Chinese medicine in Victoria Semi-legitimized professionalized heterodox medical systems Chinese medicine outside of Victoria Naturopathy or natural therapies Direct-entry midwifery Homeopathy Limited or marginal heterodox medical systems Homeopathy Massage therapy Reflexology Reiki Kinesiology Religious healing systems Spiritualism Pentecostalism Liberal Catholic Church Scientology New Age healing Folk and ethnic medical systems Anglo-Australian folk medicine European immigrant groups’ folk medical systems Asian folk medical systems Aboriginal medical systems 192 Chapter 7 statutory registration for chiropractors in that state and included them under pri- vate health insurance plans; and (4) the period of legitimation, which\ began with a federal parliamentary committee report in 1977 that recommended registration for both chiropractors and homeopaths although not naturopaths (Willis 1989).

Chiropractic and osteopathy constitute fully legitimized professionalized hetero- dox medical systems in the sense that their training programs are embedded in public universities and one private university, namely, the chiropractic program at Murdoch University.

Chinese Medicine in Australia Although traditional Chinese medicine was first introduced in Australia in the mid-1850s in places like the gold fields of Victoria, where Chinese migrants first settled, it did not attain widespread popularity until the development of the holistic health movement. Chinese medicine has been and continues to be \ a fractionated profession as is evidenced by its wide array of associations and pri- vate training programs, some of which are situated in Chinese medicine colleges and others in colleges of natural therapies. Four public universities, n\ amely, the Royal Melbourne Institute of Technology, the University of Western Sydney, the University of Technology–Sydney, and Victoria University, offer degree pro- grams in Chinese medicine. Despite the opposition of organized biomedicine, the Victoria Parliament passed the Chinese Registration Act in May 2000, mak- ing Victoria the only Australian jurisdiction to formally recognize regular Chinese medicine practitioners. However, Chinese medicine later obtained federal stat- utory registration under the Allied Health Professions Act. In essence, Chinese medicine finds itself situated on the border between fully legitimized and partially legitimized status as a heterodox medical system.

Naturopathy The historic development of Australian naturopathy can be divided into three periods: its emergence between the 1920s and 1940s, a holding pattern between the 1950s and early 1970s, and its explosion from the late 1970s to the present under the umbrella of the holistic health movement. While the terms “naturopath” and “naturopathy” continue to be used in a variety of contexts in Australia, including academic programs and professional associations, the terms “natural therapies” and “natural medicine” have become\ commonplace and are applied to a wide array of therapeutic subsystems, including Western herbalism, acupuncture, massage therapy, homeopathy, reflexology, and aro- matherapy. Naturopathy constitutes a semi-legitimized professionalized het- erodox medical system in that it has not achieved statutory registration in any political jurisdiction. It for a while achieved some degree of legitimation inas- much as naturopathic training programs became situated in public institutions of higher education or in partnerships with private colleges and public universities.

The fact that both the federal government and certain state governments have Plural Medical Systems 193 commissioned inquiries into various aspects of CAM also constitutes a de\ facto form of legitimation.

Lay or Direct-Entry Midwifery There are a large number of nurse-midwives in Australia, as in other Western societies. The women’s liberation movement stimulated development of the natural childbirth movement in Australia. Several public universities, i\ ncluding Flinders University in Adelaide and Monash University in Melbourne, came to offer direct-entry programs in which midwifery is offered as an undergraduate degree.

Organizations that promote lay midwifery care in both hospitals and homes include the Australian College of Midwives, the Australian Society of In\ dependent Midwives, a consumer group called Maternity Coalition, and the Community Midwifery Program, which since 1990 has been funded by the government to seek alternative models of childbirth for low-risk women (Sutton 2004:6–7).

Teaching CAM Other alternative therapeutic systems such as homeopathy, massage therapy, reflexology, aromatherapy, Reiki, polarity therapy, kinesiology, and various other CAM therapies constitute limited or marginal heterodox medical systems in Australia. Many of these systems function as specific treatment modalities that are taught in schools of natural therapy or that are used as adjuncts by naturopaths or natural therapists in their practices. Furthermore, when the tenets of these sub- systems are taught at a school of natural therapy as a specialized program of study or at a training institution that focuses on a specific therapy, such as home- opathy or reflexology, they often entail a shorter period of study and the granting of a “diploma” or “certificate” rather than a “degree” or “advanced diploma.” At the next level, one finds various Euro-Australian religious healing systems, such as Christian Science, Spiritualism, Seventh-Day Adventism, the Libe\ ral Catholic Church, Scientology, New Age healing, and Pentecostalism. Finally, as a multiethnic society, Australia has numerous folk medical subsystems. Of these, aboriginal healing systems in particular have received considerable attention, particularly from anthropologists. In contrast, the folk medical systems of various European and Asian immigrant groups have received relatively little attention. A study of the health status of Korean immigrants in Sydney revealed that most of them take hanbang (which, in Korean, means Chinese medicine) herbal medi- cine and health food, such as ginseng and deer antlers, but also rely heavily on biomedicine (Han 2000).

CAM and Biomedicine In the past, the Australian Medical Association (AMA) had been a virul\ ent oppo- nent of CAM. Despite the policies of the AMA, many biomedical general pr\ ac- titioners have been adopting CAM therapies, especially acupuncture, or are now willing to refer patients to CAM therapists. Discussion of CAM reportedly 194 Chapter 7 has been introduced into the undergraduate curriculum of several biomedical schools. Moreover, in 1992, various biomedical physicians formed the Australian Integrative Medicine Association. Ironically, as a result of the increasing popular - ity of CAM, the AMA has in recent years relaxed its long-standing dismissal of CAM systems (Easthope et al. 2000).

As in other developed societies, the corporate class and the state in Au\ stralia have since the 1970s come to express concern about rising health-care costs.

The growing support in various ways for CAM exhibited by the Australian gov - ernment may constitute a covert strategy for curtailing rising health costs. Given that CAM subsystems often emphasize individual responsibility for health, they are compatible with the strong interest among government health administra- tors, health policy makers, and academics in preventive medicine and health promotion. Since the 1970s, both Labor and Coalition (Liberal and Nationa\ l parties) governments have encouraged citizens to obtain private health insur - ance and have sought to make them more self-reliant and responsible (White 2002:95). The government’s support for CAM is an integral part of its neoliberal effort to divest itself of as much health-care expenditure as the Australian public will tolerate. While the federal government provides support for complementary medicine programs, which tend to be relatively inexpensive compared to bio- medical schools because of their low-tech approach, for the most part it does not provide reimbursement under the guidelines of Medicare—the Australian national health plan—to complementary practitioners for services rendered.

Periodically, the issue of whether the government should reimburse com- plementary practitioners for their services arises. Several years ago, Medicare created new regulations that all patients with a referral from a biomedical general practitioner could receive free chiropractic or osteopathic treatment. However, the Enhanced Primary Care plan permits reimbursement for only five visits per year. Given that chiropractors in particular are prone to treat patients on a quite-regular basis, the patient will be forced to either pay for additional visits out of pocket or receive a partial rebate (perhaps around 20 percent) from a private health plan.

The future of CAM as well as integrative medicine in Australia is difficult to predict but will be subject to numerous larger political, economic, and social structural forces in the larger society. So long as CAM is not fully incorpo - rated into Medicare, it will tend to serve primarily the more affluent sectors of Australian society. Patients who use CAM “represent a generally more privileged segment of the Australian population” (Gray 2006:245). Furthermore, although chiropractors, osteopaths, naturopaths, Western herbal medicine practitioners, homeopaths, and Chinese medicine practitioners view themselves as primary care practitioners, so long as they cannot practice in hospitals on a regular basis, they will remain subordinate partners in the Australian dominative medical system. Plural Medical Systems 195 Integrative Medicine as a Biomedical Specialty Integrative medicine has by and large evolved into a biomedical specialt\ y that incorporates or even, one could argue, co-opts CAM therapies and CAM pra\ c- titioners. This is highlighted by an ethnographic study with four clinic\ al fellows (Salkeld 2014) of an integrative medicine training program at the University of Arizona. The clinical fellows, all biomedical physicians, drew upon the exper - tise of selected CAM therapists, namely practitioners of naturopathic medicine, traditional Chinese medicine, energy medicine, botanical medicine, mind-\ body therapy, manual medicine, and a sleep hygienist, as well as a few spiritually o\ ri- ented practitioners, including a Christian minister and a practitioner w\ ho focused in chakra balancing and past life therapy. In assessing patients’ histories, the fellows examined biomedical diagnosis, family relationships, religious orien- tation, nutrition, and experience with CAM, thus making their approach much more holistic than conventional biomedical physicians. While the fellows so\ ught input from the CAM practitioners in their observations of patients, they never challenged a biomedical diagnosis in the study. Furthermore, as the researcher observed (Salkeld 2014:62), “although fellows in this case conference study felt comfortable incorporating select complementary therapies, they were reluctant to adopt explicitly different explanations for disease etiology,” thus preserving biomedical dominance over CAM.      Typologies of Plural Medical Systems A number of social scientists have created typologies to help understand\ the nature of medical pluralism in complex societies of the sort described in the three cases that were presented here. Drawing on the meaning-centered perspect\ ive, one model delineates three overlapping sectors in the health-care system\ (Chris- man and Kleinman 1983). The popular sector consists of health care perf\ ormed by patients themselves along with their families, social networks, and c\ ommu- nities, or the “therapeutic management group” (Janzen 1978:4–5). It includes a wide range of therapies, such as special rituals, diets, prohibitions \ on certain behaviors, herbs, teas, exercise, rest, baths, and massage, as well as, \ with the rise of commercial pharmacies, articles such as over-the-counter drugs, vitam\ in and nutritional supplements, humidifiers, heating pads, and hot water bott\ les. The second level of this typology, the folk sector, encompasses various \ healers who are self-trained or undergo an apprenticeship and tend to pr\ actice independently, often out of their home on a quasi-legal or illegal basis\ . These include shamans, mediums, magicians, herbalists, bonesetters, lay midwives, psy- chics, and faith healers, such as the Maprofeita healer from Mozambique \ shown in figure 7.1. An example of the folk sector was described in chapter \ 2 in the case of Brodwin’s study of houngans in Haiti and the ways in which people make decisions about which type of healer to consult when they feel ill. 196 Chapter 7 The professional sector includes the practitioners and bureaucratic structures, such as clinics, hospitals, and associations, that are associated with b\ oth biomed- icine and professionalized heterodox medical systems, such as Ayurveda a\ nd Unani in South Asia; acupuncture and herbalism in China; homeopathy, ost\ eop- athy, chiropractic, and naturopathy in Britain; and Heilpraktikers (naturopaths) in Germany. The department of surgery studied by Katz that was presented\ in chapter 2 is an example of one part of the professional sector in biomed\ icine. Healing and History In the previous chapter we introduced Fabrega’s biocultural approach \ to medical systems, in which he maintains that medical pluralism is first manifested in chief- dom societies, prestate societies, and early state societies and then de\ velops an even more elaborate form in more complex societies, starting out with empires and civilizations, such as ancient China, ancient India, ancient Greece, and\ medieval Islamic societies, followed by European societies and finally postmode\ rn societies. According to Fabrega, in state societies, sickness and health adaptation\ (SH) is characterized by two tiers: (1) an official, scholarly, academic \ medical system oriented to the care of elites and (2) a wide array of less prestigious physicians FIGURE 7.1 Maprofeita faith healer in urban Mozambique. Photo by Ippolytos Andreas Kalofonos. Plural Medical Systems 197 and folk healers who treat subordinate segments of the society. The stat\ e, with its various government bodies, plays an increasing role in medical care \ by hiring practitioners for elites and providing free or nominal care for the poor\ , especially during famines and epidemics. The literate or “great” medical tradition, such as in traditional Chinese medicine or Ayurveda in South Asia, includes the forma- tion of a medical profession, the beginnings of clinical medicine, and i\ ncreasing commercialization (and technologization) of the healing endeavor. The first literate or “great medical tradition” commenced in the\ ancient city-state of Sumer and its hinterland, the first instance of medical \ pluralism in an early state society. Sumeria, which existed between 4000 and 3000 BCE\ , pos- sessed three categories of cuneiform texts that included various kinds of medical information: therapeutic or medical texts per se, omen collections or “\ symptom texts,” and miscellaneous texts that included information on ailments\ and medical practices (Magner 1992:19). Sumerian physicians diagnosed symptoms by taking health histories rather than performing direct physical examination. Con\ versely, the “conjurer,” “diviner,” or “priest-healer” in Sumer\ society conducted a direct physical examination and used the patient’s symptoms and life circums\ tances as omens to help diagnose disease. The Sumerian pharmacopoeia included 2\ 50 medicinal plants and some 120 mineral substances as well as alcoholic be\ verages, fats and oils, animal parts and products, honey, wax, and various kinds \ of milk. In the centuries after Sumer, various empires and civilizations develope\ d particularly elaborate corpora of medical knowledge, such as manifested \ in tradi- tional Chinese medicine and Ayurveda in South Asia, that are incorporate\ d into writings and commentaries that over time both exhibit an internal order \ and also include numerous inconsistencies. While much has been written about medical systems in Old World ancient empires and civilizations, out of which bio\ medicine ultimately developed, including those of Egypt, Greece, and Rome, far le\ ss has been written about the medical systems of New World civilizations and em\ pires, such as those of the Mayas, Aztecs, and Incas. The Aztecs, who developed an extensive empire in central Mexico that ended with the Spanish conquest in the early sixteenth century, had a co\ m- plex medical system that combined naturalistic and supernaturalistic ele\ ments and included priests, shamans, and physicians (Ortiz de Montellano 1989\ ).

The state-sanctioned presence of both priests and shamans was a unique s\ itua- tion worldwide because of the strong antagonism that generally exists be\ tween the two. The Aztecs believed that the human body contains several souls,\ each with a specific function affecting growth, development, physiology, an\ d fate in the afterlife. The three primary souls were the tonally, situated in the head; the teyolia, located in the heart; and the ihiyotl, found in the liver. Health depended on the relative size of each soul at any point in time and the degree of\ balance among the three souls. Diet and personal behavior influenced the size of each soul. Offended deities, particularly the creator god Tezcatlipoca (or o\ ne of his many manifestations), or certain animals could inflict disease on an \ individual.

Aztec astrology posited that the equilibrium of the universe affected th\ e human body. The Aztecs also believed that disease could be inflicted by a so\ rcerer through certain rituals. 198 Chapter 7 The Aztec priesthood became more elaborate and specialized as the Aztec \ civilization and empire expanded. Various sorts of priests officiated \ at rituals, including those featuring human sacrifice; managed temple treasuries; \ taught school; listened to confessions and prescribed penance (Wolf 1999:153)\ . Priests conducted worship of the Aztec pantheon that consisted of numerous deiti\ es, each of which had one or more temples where its idol was kept. The vast \ majority of priests were males, but there were some female priests who generally \ served briefly before marrying. Aztec shamans were capable of sending their tonally on magical flights back to the time of creation or, alternatively, transforming them into the ap\ pearance of an animal. This process of spiritual transformation by the shamans wa\ s assisted by the use of various hallucinogenic plants. Shamans focused on curing a\ ilments caused by imbalance in the relationships between the gods and humans or \ by the intrusion of beings from other cosmic realms into the sufferer’s body\ . Aztec physicians could be either male or female. Sahagun, a Catholic pri\ est who chronicled many aspects of Aztec culture following the Spanish conqu\ est, described the good general practitioner as being one who worked with her\ bs, stones, and roots; examined, experimented, and alleviated disease; set b\ ones and administered massages, purges, and potions; bled his or her patients; an\ d dressed wounds (Smith 2003:255). Aztec medicine also had an array of medical specialists who focused on diagnosing specific ailments by identifying the offended deity who had\ induced the disease and prescribing the appropriate propitiatory ritual, which c\ ould be making an offering, confessing a wrongdoing, engaging in acts of penance\ , or praying. It included, as well, empirical knowledge about hundreds of med\ icinal plants that were applied by herbal specialists. The Aztec medical system\ relied on highly sophisticated surgeons, including those who served in the many ba\ ttles that the Aztecs fought while enlarging their empire, some of whom even p\ rac- ticed plastic surgery. Aztec society also had fortune-tellers who could \ be either male or female and who divined by casting maize kernels and gazing in wa\ ter. Sickness and health adaptation in modern state societies worldwide is characterized by the emergence of biomedicine as a dominant and hegemoni\ c profession. Biomedicine, in turn, is characterized by patterns of secula\ rization, including the weakening of the role of institutional religion in public \ life; sci- entific knowledge, with its embrace of biological reductionism, including the tendency to view disease as due primarily to biological factors, such as\ germs; the emergence of the hospital as the center of healing and research; and\ the universalization of categories of sickness. For many social scientists, \ modernity is generally associated with the rise of advanced technology, conventional \ Western science, the notion of progress, rationalism, efficiency, and seculari\ zation. In this scenario, the hospital emerges as the center of healing and the “clin\ ical gaze” in which the body is subjected to close probing and scrutiny, such as in th\ e use of the stethoscope and surgery. Biomedicine during the modern era became increasingly specialized with the appearance of practitioners who focused on certain parts of the body\ , such as the heart, the lungs, and the immunological system. Furthermore, in k\ eeping Plural Medical Systems 199 with a pattern of medical specialization is the “growth of the discip\ line of psychi- atry and the increasing importance given to mental illness in the societ\ y and in conceptions of social disability, welfare, and crime” (Fabrega 1997:\ 136). At the same time, medical pluralism in Western societies and Japan manifests it\ self in the continuing existence of alternative practitioners, such as homeopaths, h\ erbalists, osteopaths, chiropractors, and naturopaths, who are held in contempt by \ many biomedical physicians. Despite persisting biomedical dominance, the pursuit of alternative thera- pies, including ones based on Western spirituality or Eastern mysticism,\ manifests itself most profoundly in what Fabrega and other social scientists term \ postmod- ern societies. The postmodern world is associated with corporate globali\ zation involving the diffusion of corporate control over economic, political, a\ nd cultural processes throughout the world; a sense of social fragmentation and unce\ rtainty about social institutions and values; an emphasis on consumerism; a grow\ ing faith in intuition; and “hybridity,” which is the blending of elem\ ents from dif- ferent cultures and parts of the world. Many individuals in postmodern s\ ocieties, particularly those belonging to higher socioeconomic categories, regard \ health as an achieved status obtained through education, prevention, and lifest\ yle. Fur- ther, postmodern societies manifest an “obsessive preoccupation with \ health and fitness” (Fabrega 1997:137), thus resulting in the phenomenon of \ the “worried well.” Patients of CAM These patterns result in “dissatisfaction with physicians, with ‘e\ stablishment’ medicine, with the escalating costs of a more routinized and procedural \ approach to healing, and with tentacles of medical insurance companies,”\ all leading to an “increasing interest in holistic medical traditions and\ the growth of health-promoting and life extension industries that compete with orth\ odox biomedicine” (Fabrega 1997:244). Numerous patient utilization studies conducted in the United States, Can- ada, Britain, Australia, and various Western European countries have sou\ ght to identify the types of people who tend to turn to complementary and alter\ native therapies and practitioners. These studies indicate that users of CAM, a\ side from various folk medical systems, tend to be female, relatively young, emplo\ yed, highly educated, and often but not necessarily involved in alternative l\ ifestyles.

Based upon interviews with seventeen “high performing” individuals\ , all of whom had tertiary levels of education, in the Canadian province of Alber\ ta, CAM has been found in part to function as a self-care system, entailing \ practices such as vegetarian and vegan diets, yoga, meditation, and tai chi (Frie\ s 2013). At the same time, CAM has found some reception among working-class people in developed societies. One study, for example, found that many o\ f the researcher’s respondents in Oceanport (pseudonym), a suburb of an A\ ustralian city, reported that they and other household members followed a “mixe\ d therapy regimen” in which they used a CAM therapy either prior to or in combi\ nation with biomedical treatment (Connor 2004). 200 Chapter 7 CAM often overlaps with New Age spirituality and New Age Orientalism and for affluent Westerners may entail travel to health spas in developing\ countries, particularly India. For example, Vedic Village in India offers its clien\ ts access to five holistic physicians, two of whom have degrees in Ayurvedic medici\ ne and surgery and three of whom have degrees in homeopathic medicine and surge\ ry (Nazrul 2012). One of the holistic physicians has naturopathic trainin\ g and the other five hold expertise in acupuncture. In addition to the Western v\ isitors to Vedic Village, the site is visited by Indian middle-class professional p\ eople or wealthy business people who seek relaxation therapy (Nazrul 2012).

CAM in Denmark Based upon interviews with forty CAM practitioners and three hundred pat\ ients of CAM clinics in Denmark, one study delineates three principal actor-ne\ tworks:

a technocrat network, a social-democratic network, and a neoliberal netw\ ork (Johannessen 2007). The technocrat network exhibits body praxis that o\ perates with a plumbing model in which the body is viewed as a series of pipes t\ hat “reflects technologies of drainage systems, circulation of water, h\ eat and electric- ity in the house so familiar to contemporary people” (Johannessen 2007:270).

In Danish CAM clinics, reflexology in particular, which entails the ma\ ssage of reflex zones on the feet that are purportedly linked with various orga\ ns, follows the plumbing model associated with the technocrat network. The social-democr\ atic network model seeks to achieve an internal balance among body organs refl\ ective of the need for a more macroscopic balance between the body’s immune \ system and external disease agents, such as allergens, pollutants, bacteria, and viruses.

CAM therapies focused upon proper nutrition and the technologies of biopa- thy illustrated, for instance, by use of an “electrical apparatus sho\ wing signs of light and sound” exemplify this model, which is characterized by “\ principles of democracy, consultancy, and uniqueness” (Johannessen 2007:273). Fin\ ally, the neoliberal network model views the body as a computer governed by the brain that can be corrected through a process of reprogramming when an autonom\ ous individual begins to malfunction. In order to reprogram the patient’s body-mind, kinesiology with its tests of muscle strengths operates on the basis of \ this model in that its practitioners administer bodywork based upon patients’ re\ sponses to questions about their experiences in childhood and even previous lives, \ substance intolerance, malfunctioning organs, and strained social relations. Patie\ nts may prefer one or another actor-network, but in reality they move between th\ em, thus following a sort of mixed therapy regimen within the confines of CAM.

Traditional Healers in Mozambique While CAM systems have, since the 1970s, become increasingly popular in \ developed societies, the high cost of biomedicine and the fact that it t\ ends to be based in urban areas means that many people in developing societies, \ partic- ularly in rural areas but also in cities, continue to rely heavily on “\ traditional” medical systems or on new healers who combine aspects of folk medicine a\ nd biomedicine. A study of indigenous and church-based healers in Mozambiqu\ e revealed that traditional healing has been altered appreciably due to th\ e impacts Plural Medical Systems 201 of both colonialism and market capitalism (Pfeiffer 2005). Men, in par\ ticu- lar, in poverty-stricken Mozambique have responded to structural adjustm\ ent policies imposed on their country by the World Bank and the Internationa\ l Monetary Fund in 1987 by turning to traditional healing as a means of ma\ king a livelihood. Indeed, the Mozambique Association of Traditional Healers,\ a government-based body to which many curandeiros belong, lists the availability of numerous treatments, including ones to help a client obtain a job, av\ oid mis- haps, contact ancestral spirits, and cope with a wide array of problems \ of living.

Some traditional healers, however, view the association as a government ploy to tax them. In response to the growing pecuniary orientation of many tradi\ tional healers, a large number of people in Mozambique have turned to Pentecost\ al sects and African independent churches, which syncretize or blend elemen\ ts of traditional African religions and Christianity, to create healing ritual\ s designed to help them cope with their plight.

CAM and Class In keeping with Navarro’s (1986:1) assertion that classes as well a\ s ethnic groups and genders within capitalist societies “have different ideologies wh\ ich appear in different forms of culture,” it may be argued that these social categ\ ories also con- struct different health understandings, behavior patterns, and medical s\ ubsystems to coincide with their respective views of reality. Regarding gender dif\ ferences, for example, various medical anthropologists concerned with reproductive health have argued that men and women do not always share reproductive goals an\ d strategies. As has been observed, “Contested reproductive interests m\ ay derive from women’s and men’s differing experiences of pregnancy and birt\ h, varying domestic and productive responsibilities, or discrepant material interests” (Sar- gent 2006:32). How men influence women’s reproductive behaviors, i\ n fact, remains an understudied issue. One possible reason for this is that earl\ ier anthro- pologists viewed reproduction as a women’s issue, and therefore perip\ heral to the discipline, a telling comment on how social factors influence the \ course of social research within and beyond medical anthropology, an issue address\ ed in chapter 2 (Browner 2001:773). Class differences in health understandings, behaviors, and medical subsys- tems are also of considerable importance. Critical medical anthropologists, for example, argue that the patterns of medical pluralism found in state soc\ ieties tend to reflect hierarchical and unequal social relations based on class, c\ aste, ethnicity, region, religion, and gender distinctions found in the larger society. T\ hus, critical medical anthropologists argue that national medical systems in the moder\ n world should be described as “plural” rather than “pluralistic” in\ asmuch as biomedicine enjoys a dominant status over both heterodox